Provider Demographics
NPI:1033144597
Name:ELLIS, GEORGE FREDERICK (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:FREDERICK
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD
Mailing Address - Street 2:FL 2
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:89 W COPELAND DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2002
Practice Address - Country:US
Practice Address - Phone:321-842-6910
Practice Address - Fax:321-843-5998
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163161208800000X
FLME49437208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273075800Medicaid
FLME49437OtherMEDICAL LICENSE
FL273075800Medicaid