Provider Demographics
NPI:1093860090
Name:ELLIS, JEFFREY WARREN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WARREN
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 1:2701 MEREDYTH DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-2267
Mailing Address - Country:US
Mailing Address - Phone:229-430-9213
Mailing Address - Fax:229-903-1585
Practice Address - Street 1:2701 MEREDYTH DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-2267
Practice Address - Country:US
Practice Address - Phone:229-430-9213
Practice Address - Fax:229-903-1585
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034582207V00000X
MI4301071108207V00000X
IN01047231A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200299850Medicaid
INP01723961OtherRR MEDICARE
INP01723961OtherRR MEDICARE
IN266180741Medicare PIN