Provider Demographics
NPI:1164694634
Name:ELMORE, ELLEN (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ELMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11149 RESEARCH BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5279
Mailing Address - Country:US
Mailing Address - Phone:512-231-1901
Mailing Address - Fax:512-231-1902
Practice Address - Street 1:11149 RESEARCH BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5279
Practice Address - Country:US
Practice Address - Phone:512-231-1901
Practice Address - Fax:512-231-1902
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-25
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI8800207Q00000X
AK6418207Q00000X
TXP2852207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX313465202Medicaid
TX313465201Medicaid
TX263036YKXYMedicare PIN
TX313465201Medicaid
TX313465202Medicaid