Provider Demographics
NPI:1093762908
Name:ELLIS, CLYDE NEAL JR (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:NEAL
Last Name:ELLIS
Suffix:JR
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 1:2435 FIRE MESA ST
Mailing Address - Street 2:# 110A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-9009
Mailing Address - Country:US
Mailing Address - Phone:702-853-3300
Mailing Address - Fax:
Practice Address - Street 1:2435 FIRE MESA ST STE 110A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-9009
Practice Address - Country:US
Practice Address - Phone:725-200-3242
Practice Address - Fax:702-664-3242
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19367208C00000X
PAMD440703208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1093762908Medicaid
ALP00243607OtherRAILROAD MEDICARE PTAN
AL009948045Medicaid
AL009948065Medicaid
AL51520900OtherBLUE CROSS
AL14-10031OtherUNITED HEALTH CARE
AL051520900Medicare PIN
AL14-10031OtherUNITED HEALTH CARE