Provider Demographics
NPI:1609814425
Name:ELLIS, DAVID MARTIN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MARTIN
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SOUTHGATE PKWY
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:OH
Mailing Address - Zip Code:43725-2325
Mailing Address - Country:US
Mailing Address - Phone:740-432-6556
Mailing Address - Fax:740-432-2506
Practice Address - Street 1:123 SOUTHGATE PKWY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-2325
Practice Address - Country:US
Practice Address - Phone:740-432-6556
Practice Address - Fax:740-432-2506
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36001852213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0448788Medicaid
0484535Medicare PIN
OH0448788Medicaid
9290001Medicare PIN
T80496Medicare UPIN
0484534Medicare PIN