Provider Demographics
NPI:1386748168
Name:ELLEDGE, ELLIOTT FREDERICK (MD)
Entity type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:FREDERICK
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:E.
Other - Middle Name:FRED
Other - Last Name:ELLEDGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:235 S NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-3135
Mailing Address - Country:US
Mailing Address - Phone:760-754-2326
Mailing Address - Fax:
Practice Address - Street 1:235 S NEVADA ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-3135
Practice Address - Country:US
Practice Address - Phone:760-754-2326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43048208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABE3388673OtherDEA#
CAF3951Medicare UPIN