Provider Demographics
NPI:1598956492
Name:ELLIS-COLANDRO, CARRIE DIANE (DO)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:DIANE
Last Name:ELLIS-COLANDRO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:DIANE
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1225 E WEISGARBER RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-2604
Mailing Address - Country:US
Mailing Address - Phone:865-584-4747
Mailing Address - Fax:865-584-1363
Practice Address - Street 1:7541 CROSSWOOD BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-3935
Practice Address - Country:US
Practice Address - Phone:865-524-1661
Practice Address - Fax:865-523-8406
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3721613OtherMEDICARE GROUP #
TN3721613OtherMEDICARE GROUP #