Provider Demographics
NPI:1063507432
Name:CIVELLO, ELLIS JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:JOHN
Last Name:CIVELLO
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 1:721 THOMPSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78028
Mailing Address - Country:US
Mailing Address - Phone:830-896-2211
Mailing Address - Fax:
Practice Address - Street 1:721 THOMPSON DRIVE
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028
Practice Address - Country:US
Practice Address - Phone:830-896-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG70462084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139933924Medicaid
TX8D1118Medicare ID - Type Unspecified
TX139933924Medicaid