Provider Demographics
NPI:1437240124
Name:ELLIS, MARK OWEN (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:OWEN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 22ND STREET
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103
Mailing Address - Country:US
Mailing Address - Phone:503-325-0045
Mailing Address - Fax:503-325-3242
Practice Address - Street 1:582 22ND STREET
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103
Practice Address - Country:US
Practice Address - Phone:503-325-0045
Practice Address - Fax:503-325-3242
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00095213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR056416Medicaid
T88040Medicare UPIN
OR056416Medicaid