Provider Demographics
NPI:1073515300
Name:ELLIS, WILLIAM W (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:W
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 1:116 MIMOSA DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6605
Mailing Address - Country:US
Mailing Address - Phone:229-551-0083
Mailing Address - Fax:229-227-9642
Practice Address - Street 1:116 MIMOSA DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6605
Practice Address - Country:US
Practice Address - Phone:229-551-0083
Practice Address - Fax:229-227-9642
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA015666207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00264195AMedicaid
GAD45281Medicare UPIN
GA00264195AMedicaid