Provider Demographics
NPI:1598865438
Name:ELLISON, MATTHEW D (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:D
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3480 WAKE FOREST RD STE 404
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7376
Mailing Address - Country:US
Mailing Address - Phone:919-862-5730
Mailing Address - Fax:919-862-5733
Practice Address - Street 1:3480 WAKE FOREST RD STE 404
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7376
Practice Address - Country:US
Practice Address - Phone:919-862-5730
Practice Address - Fax:919-862-5733
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA67446207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG92942Medicare UPIN