Provider Demographics
NPI:1518919406
Name:ELLISON, JULIA CENTANNI (DO)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:CENTANNI
Last Name:ELLISON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6701 AIRPORT BLVD STE D143
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-6701
Mailing Address - Country:US
Mailing Address - Phone:251-342-3949
Mailing Address - Fax:251-266-3361
Practice Address - Street 1:411 N SECTION ST
Practice Address - Street 2:
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-2649
Practice Address - Country:US
Practice Address - Phone:251-660-3470
Practice Address - Fax:251-660-3471
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO850207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005825Medicaid
ALDO850OtherMEDICAL LICENSE
AL51119080OtherBC
AL102I084178Medicare PIN
AL51119080OtherBC
WVEL6037051Medicare PIN
WV3810005825Medicaid