Provider Demographics
NPI:1962798629
Name:DIAMOND, ELLIS RAPHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:RAPHAEL
Last Name:DIAMOND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3554 CALLE PALMITO
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-8958
Mailing Address - Country:US
Mailing Address - Phone:760-436-5010
Mailing Address - Fax:760-436-5523
Practice Address - Street 1:3554 CALLE PALMITO
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-8958
Practice Address - Country:US
Practice Address - Phone:760-436-5010
Practice Address - Fax:760-436-5523
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG359712084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology