Provider Demographics
NPI:1588637813
Name:ELLIS, DEMETRIUS (MD)
Entity Type:Individual
Prefix:DR
First Name:DEMETRIUS
Middle Name:
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 1:3414 5TH AVE
Mailing Address - Street 2:CHOB BUILDING, 1ST FLOOR
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15213-3205
Mailing Address - Country:US
Mailing Address - Phone:412-692-5182
Mailing Address - Fax:
Practice Address - Street 1:3414 5TH AVE
Practice Address - Street 2:CHOB BUILDING, 1ST FLOOR
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15213-3205
Practice Address - Country:US
Practice Address - Phone:412-692-5182
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD015639E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA132119EB0Medicare ID - Type Unspecified
PAD71225Medicare UPIN