Provider Demographics
NPI:1225186901
Name:ELLIS, JOSEPHINE (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPHINE
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:
Other - Last Name:THANGATHURAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MBBS
Mailing Address - Street 1:2561 LAC DE VILLE BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-5645
Mailing Address - Country:US
Mailing Address - Phone:585-244-7330
Mailing Address - Fax:585-244-6958
Practice Address - Street 1:2561 LAC DE VILLE BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-5645
Practice Address - Country:US
Practice Address - Phone:585-244-7330
Practice Address - Fax:585-244-6958
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266694207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02862655Medicaid