Provider Demographics
NPI:1285635052
Name:ELLERIN, BRUCE ELKIN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ELKIN
Last Name:ELLERIN
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 1:721 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2043
Mailing Address - Country:US
Mailing Address - Phone:903-533-6312
Mailing Address - Fax:903-535-6330
Practice Address - Street 1:721 CLINIC DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2043
Practice Address - Country:US
Practice Address - Phone:903-535-6312
Practice Address - Fax:903-535-6330
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL86792085R0001X, 2085R0001X
KS04-318772085R0001X
IL036.1283372085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1825753OtherAETNA
TX1984247-03Medicaid
TX1984247-04Medicaid
010046338OtherAMERICHOICE
3K8111OtherHEALTHNET
P3883771OtherOXFORD
MO1285635052Medicaid
010046338OtherAMERICHOICE
MOMA3347034Medicare PIN
KS200386280CMedicaid
P3883771OtherOXFORD
KS200386280BMedicaid
KSK40000085Medicare PIN