Provider Demographics
NPI:1457322760
Name:ELLIS, LEIGHTON ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:LEIGHTON
Middle Name:ELIZABETH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:12201 RENFERT WAY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-5354
Mailing Address - Country:US
Mailing Address - Phone:512-491-5125
Mailing Address - Fax:512-491-8521
Practice Address - Street 1:12201 RENFERT WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-5354
Practice Address - Country:US
Practice Address - Phone:512-491-5125
Practice Address - Fax:512-491-8521
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2007-07-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXK2457208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG07196Medicare UPIN