Provider Demographics
NPI:1316000276
Name:ROBERT D. ELLIS, O.D. P.A.
Entity Type:Organization
Organization Name:ROBERT D. ELLIS, O.D. P.A.
Other - Org Name:AROOSTOOK FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:207-532-6503
Mailing Address - Street 1:40 COURT ST
Mailing Address - Street 2:
Mailing Address - City:HOULTON
Mailing Address - State:ME
Mailing Address - Zip Code:04730-2002
Mailing Address - Country:US
Mailing Address - Phone:207-532-6503
Mailing Address - Fax:207-532-3208
Practice Address - Street 1:40 COURT ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-2002
Practice Address - Country:US
Practice Address - Phone:207-532-6503
Practice Address - Fax:207-532-3208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT525152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MET31713Medicare UPIN
MEMM6696Medicare ID - Type Unspecified