Provider Demographics
NPI:1083776611
Name:ELLIS, JERRY H (OD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:H
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 1:197 HOSPITAL DRIVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHEROKEE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:72529-7315
Mailing Address - Country:US
Mailing Address - Phone:870-257-2100
Mailing Address - Fax:870-257-4395
Practice Address - Street 1:197 HOSPITAL DRIVE
Practice Address - Street 2:SUITE A
Practice Address - City:CHEROKEE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:72529-7315
Practice Address - Country:US
Practice Address - Phone:870-257-2100
Practice Address - Fax:870-257-4395
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2408152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR128855722Medicaid
AR48729Medicare ID - Type UnspecifiedMEDICARE
ARU43016Medicare UPIN