Provider Demographics
NPI:1346230836
Name:ELLIS, ANNISHA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNISHA
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 MULKEY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-1151
Mailing Address - Country:US
Mailing Address - Phone:770-819-9262
Mailing Address - Fax:678-945-1295
Practice Address - Street 1:1810 MULKEY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-1151
Practice Address - Country:US
Practice Address - Phone:770-819-9262
Practice Address - Fax:678-945-1295
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053849208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics