Provider Demographics
NPI:1114000403
Name:ELLISON, THOMASENA L (MD FACOG)
Entity Type:Individual
Prefix:
First Name:THOMASENA
Middle Name:L
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD FACOG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LIVINGSTON STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201
Mailing Address - Country:US
Mailing Address - Phone:718-222-0393
Mailing Address - Fax:718-222-3653
Practice Address - Street 1:100 LIVINGSTON STREET
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201
Practice Address - Country:US
Practice Address - Phone:718-222-0393
Practice Address - Fax:718-222-3653
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1802491207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ET0249OtherATLANTIS
N323923OtherWELL CARE
0202017OtherGHI
112619613EL02OtherCARE PLUS
3C1694OtherHEALTHNET
P406658OtherOXFORD
30310POtherHIP
T4XOtherETIN
255780401OtherHEALTH PLUS
112619613EL02OtherCARE PLUS
P406658OtherOXFORD