Provider Demographics
NPI:1508826074
Name:ELLIS, LANCE A (DO)
Entity Type:Individual
Prefix:DR
First Name:LANCE
Middle Name:A
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 1:1507 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GATESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76528-1024
Mailing Address - Country:US
Mailing Address - Phone:254-865-2166
Mailing Address - Fax:254-248-0626
Practice Address - Street 1:1507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GATESVILLE
Practice Address - State:TX
Practice Address - Zip Code:76528-1024
Practice Address - Country:US
Practice Address - Phone:254-865-2166
Practice Address - Fax:254-248-0626
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101015902207XS0117X, 207XX0801X
OH34-007955207XS0117X, 207XX0801X
TXM4053207XX0005X, 207XX0801X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXM4053OtherSTATE LICENSE
TXM4053OtherSTATE LICENSE
TX8F20843Medicare PIN
TXM4053OtherSTATE LICENSE
TX211557803Medicaid