Provider Demographics
NPI:1174688857
Name:ELLIS, WALTER WRIGHT (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:WRIGHT
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 1:227 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70087-3765
Mailing Address - Country:US
Mailing Address - Phone:504-469-3438
Mailing Address - Fax:
Practice Address - Street 1:3749 N CAUSEWAY BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-2046
Practice Address - Country:US
Practice Address - Phone:504-828-8241
Practice Address - Fax:504-828-8243
Is Sole Proprietor?:No
Enumeration Date:2006-12-24
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024782204C00000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1489417Medicaid
LA1489417Medicaid
LA4F0857627Medicare ID - Type Unspecified