Provider Demographics
NPI:1467687756
Name:ELLIS, LORI J (MD)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 E MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2982
Mailing Address - Country:US
Mailing Address - Phone:631-979-7222
Mailing Address - Fax:631-638-4170
Practice Address - Street 1:260 E MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 107
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2982
Practice Address - Country:US
Practice Address - Phone:631-979-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-15
Last Update Date:2022-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY264115208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics