Provider Demographics
NPI:1225184856
Name:ELLISON, STEPHEN RUSSELL (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RUSSELL
Last Name:ELLISON
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 1:1962 FM 1478
Mailing Address - Street 2:
Mailing Address - City:LAMPASAS
Mailing Address - State:TX
Mailing Address - Zip Code:76550-3726
Mailing Address - Country:US
Mailing Address - Phone:512-556-0782
Mailing Address - Fax:
Practice Address - Street 1:1962 FM 1478
Practice Address - Street 2:
Practice Address - City:LAMPASAS
Practice Address - State:TX
Practice Address - Zip Code:76550-3726
Practice Address - Country:US
Practice Address - Phone:512-556-0782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0462207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1458101Medicaid
TX1458101Medicaid
TXH40621Medicare UPIN