Provider Demographics
NPI:1164602611
Name:ELLIS, EZRA DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:DANIEL
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:PO BOX 3293
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-3293
Mailing Address - Country:US
Mailing Address - Phone:317-614-9863
Mailing Address - Fax:844-876-0873
Practice Address - Street 1:743 SPRING ST NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3715
Practice Address - Country:US
Practice Address - Phone:770-219-1136
Practice Address - Fax:770-219-6204
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-10161207ZP0102X
NC2007-00176207ZP0102X
GA70094207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010167581OtherREGENCE BLUESHIELD OF IDAHO
ID77342OtherBLUECROSS OF IDAHO
ID808087600Medicaid
ID77342OtherBLUECROSS OF IDAHO