Provider Demographics
NPI:1225031453
Name:ELLIS, STEVEN PAUL (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:PAUL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:123 FRANKLIN CORNER RD
Mailing Address - Street 2:STE 207
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2526
Mailing Address - Country:US
Mailing Address - Phone:609-896-9448
Mailing Address - Fax:609-896-7052
Practice Address - Street 1:123 FRANKLIN CORNER RD
Practice Address - Street 2:STE 207
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2526
Practice Address - Country:US
Practice Address - Phone:609-896-9448
Practice Address - Fax:609-896-7052
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA054450207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5551200Medicaid
NJC33321Medicare UPIN
NJ5551200Medicaid