Provider Demographics
NPI:1053361790
Name:ELLY, MEHRAN K (MD, PHD)
Entity type:Individual
Prefix:
First Name:MEHRAN
Middle Name:K
Last Name:ELLY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18977
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-0550
Mailing Address - Country:US
Mailing Address - Phone:775-283-3315
Mailing Address - Fax:775-852-6902
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:EISENHOWER IMAGING CENTER
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-340-3911
Practice Address - Fax:760-674-3852
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA617162085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A617160OtherBLUE SHIELD OF CA
CA00A617160Medicaid
H14184Medicare UPIN
CA00A617160Medicaid
CA300124556Medicare PIN
CA00A617160Medicare PIN