Provider Demographics
NPI:1093737330
Name:ELLIS, BRENDA RENEE (MD)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:RENEE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7271 N MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2567
Mailing Address - Country:US
Mailing Address - Phone:937-277-9130
Mailing Address - Fax:937-277-9165
Practice Address - Street 1:7271 N MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2567
Practice Address - Country:US
Practice Address - Phone:937-277-9130
Practice Address - Fax:937-277-9165
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-8696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0753215Medicaid
OH0753215Medicaid
OHA99707Medicare UPIN