Provider Demographics
NPI:1366440919
Name:MAIN, ELLIS GERARD (DO)
Entity Type:Individual
Prefix:DR
First Name:ELLIS
Middle Name:GERARD
Last Name:MAIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10426
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78460-0426
Mailing Address - Country:US
Mailing Address - Phone:361-241-6700
Mailing Address - Fax:
Practice Address - Street 1:3022 MCKINZIE RD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78410-2628
Practice Address - Country:US
Practice Address - Phone:361-241-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137311011Medicaid
TX137311011Medicaid
TX8859N0Medicare PIN