Provider Demographics
NPI:1477632420
Name:ELLISON, JOSEPH ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ROBERT
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2725 S 107TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-2429
Mailing Address - Country:US
Mailing Address - Phone:402-393-2860
Mailing Address - Fax:402-330-5689
Practice Address - Street 1:12808 AUGUSTA AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-3733
Practice Address - Country:US
Practice Address - Phone:402-330-5690
Practice Address - Fax:402-330-5689
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11477208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47054602612Medicaid
NEF07761Medicare UPIN