Provider Demographics
NPI:1104867795
Name:ELLISON, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7908 CINCINNATI DAYTON RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-6608
Mailing Address - Country:US
Mailing Address - Phone:937-241-1830
Mailing Address - Fax:888-418-2057
Practice Address - Street 1:7908 CINCINNATI DAYTON RD
Practice Address - Street 2:SUITE J
Practice Address - City:WEST CHESTER
Practice Address - State:OH
Practice Address - Zip Code:45069-6608
Practice Address - Country:US
Practice Address - Phone:937-241-1830
Practice Address - Fax:888-418-2057
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.082208208M00000X
OH35-082208207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2411830Medicaid
OHH103671Medicare PIN
OH4107909Medicare PIN
H85207Medicare UPIN