Provider Demographics
NPI:1386702140
Name:ELLIS, RICHARD ASHLEY (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ASHLEY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12234 PANAMA CITY BEACH PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32407-2726
Mailing Address - Country:US
Mailing Address - Phone:850-233-2323
Mailing Address - Fax:850-233-1055
Practice Address - Street 1:1190 VETERANS BLVD STE C
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-2037
Practice Address - Country:US
Practice Address - Phone:650-299-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17840207Q00000X
CA12689207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12689OtherCA MEDICAL LICENSE
FE0088876OtherDEA