Provider Demographics
NPI:1417975079
Name:ELLIS, SCOTT J (OD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:J
Last Name:ELLIS
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-0009
Mailing Address - Country:US
Mailing Address - Phone:580-243-1121
Mailing Address - Fax:
Practice Address - Street 1:920 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-2829
Practice Address - Country:US
Practice Address - Phone:580-243-1121
Practice Address - Fax:580-243-1145
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist