Provider Demographics
NPI:1033290069
Name:ELLIS, EDWARD EUGENE (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:EUGENE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9525 W COAL MINE AVE APT H
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80123-8026
Mailing Address - Country:US
Mailing Address - Phone:303-979-2873
Mailing Address - Fax:
Practice Address - Street 1:9032 W KEN CARYL AVE
Practice Address - Street 2:A-5
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80128-9330
Practice Address - Country:US
Practice Address - Phone:303-973-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist