Provider Demographics
NPI:1215556667
Name:ELLIS, GRAHAM JAMES (DO)
Entity Type:Individual
Prefix:
First Name:GRAHAM
Middle Name:JAMES
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 1:330 E ROOSEVELT ST APT 4091
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-4312
Mailing Address - Country:US
Mailing Address - Phone:310-924-1413
Mailing Address - Fax:
Practice Address - Street 1:7400 BARLITE BLVD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1308
Practice Address - Country:US
Practice Address - Phone:210-921-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-15
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program