Provider Demographics
NPI:1477682003
Name:ELLIS, WILLIAM JOE (DO)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JOE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W SPENCER AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-3809
Mailing Address - Country:US
Mailing Address - Phone:765-662-9866
Mailing Address - Fax:765-668-4164
Practice Address - Street 1:424 W SPENCER AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-3809
Practice Address - Country:US
Practice Address - Phone:765-662-9866
Practice Address - Fax:765-668-4164
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02000651A204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000084415OtherANTHEM BLUE CROSS
IN100000720AMedicaid
IN100000720AMedicaid