Provider Demographics
NPI:1477724888
Name:ELLIS, CHRISTIAN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:EDWARD
Last Name:ELLIS
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 1:2500 E PRICE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521-3398
Mailing Address - Country:US
Mailing Address - Phone:239-404-6641
Mailing Address - Fax:956-621-2434
Practice Address - Street 1:100 E ALTON GLOOR BLVD # A
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3328
Practice Address - Country:US
Practice Address - Phone:239-404-6641
Practice Address - Fax:956-621-2434
Is Sole Proprietor?:No
Enumeration Date:2008-03-13
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8025207R00000X
FLME101183207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX321725ZTFPMedicare PIN
FL280965600Medicaid
FLAK028ZMedicare PIN