Provider Demographics
NPI:1508832114
Name:ELLISON, ROBERT J (MPT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2488 E 81ST ST STE 290
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4265
Mailing Address - Country:US
Mailing Address - Phone:918-927-3226
Mailing Address - Fax:918-927-3193
Practice Address - Street 1:2488 E 81ST ST STE 290
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-4265
Practice Address - Country:US
Practice Address - Phone:918-494-2665
Practice Address - Fax:918-927-3201
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK34862251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20076160AMedicaid