Provider Demographics
NPI:1871572925
Name:REILLY, ELLEN (OD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:REILLY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:CHRISTIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2350 W EL CAMINO REAL FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2025 SOQUEL AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95062-1323
Practice Address - Country:US
Practice Address - Phone:831-479-6603
Practice Address - Fax:831-458-6293
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11414T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist