Provider Demographics
NPI:1366452252
Name:ELLIS, DAVID L (PT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 S MURCHISON ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-2662
Mailing Address - Country:US
Mailing Address - Phone:903-675-0000
Mailing Address - Fax:903-675-5520
Practice Address - Street 1:115 S MURCHISON ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-2662
Practice Address - Country:US
Practice Address - Phone:903-675-0000
Practice Address - Fax:903-675-5520
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1024776225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX7416339OtherBCBS BLUE LINK #
TX81584TOtherBCBS PAR PLAN