Provider Demographics
NPI:1316395445
Name:ELLISON, STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:ELLISON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2061 BEVERLY RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2034
Mailing Address - Country:US
Mailing Address - Phone:770-532-4444
Mailing Address - Fax:770-535-1852
Practice Address - Street 1:2061 BEVERLY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2034
Practice Address - Country:US
Practice Address - Phone:770-614-8577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-31
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT02934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist