Provider Demographics
NPI:1083632244
Name:ELLIS, MARK BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BRIAN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:1018 RUCKER BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:ENTERPRISE
Mailing Address - State:AL
Mailing Address - Zip Code:36330-3675
Mailing Address - Country:US
Mailing Address - Phone:334-347-4343
Mailing Address - Fax:334-393-9611
Practice Address - Street 1:1018 RUCKER BLVD
Practice Address - Street 2:STE A
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-3675
Practice Address - Country:US
Practice Address - Phone:334-347-4343
Practice Address - Fax:334-393-9611
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2018-04-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ALDO463207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009971495Medicaid