Provider Demographics
NPI:1205832607
Name:ELLIS, CHRISTIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-749-4231
Mailing Address - Fax:405-749-4234
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:STE. 621
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-749-4231
Practice Address - Fax:405-749-4234
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3660204D00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00690379OtherRR MEDICARE
OK200084540AMedicaid
P00690379OtherRR MEDICARE
OKOK401257Medicare PIN