Provider Demographics
NPI:1003115254
Name:ELLIS, JACK BRADLEY (DO)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:BRADLEY
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 1:1499 WALTON WAY STE 1400
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2603
Mailing Address - Country:US
Mailing Address - Phone:703-724-6100
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912
Practice Address - Country:US
Practice Address - Phone:706-721-8623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA072627207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program