Provider Demographics
NPI:1609891795
Name:ELLIS, JIMMY SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:JIMMY
Middle Name:SCOTT
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 RUSSELL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CRAIG
Mailing Address - State:CO
Mailing Address - Zip Code:81625-2019
Mailing Address - Country:US
Mailing Address - Phone:970-826-2420
Mailing Address - Fax:970-826-2429
Practice Address - Street 1:785 RUSSELL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CRAIG
Practice Address - State:CO
Practice Address - Zip Code:81625-2019
Practice Address - Country:US
Practice Address - Phone:970-826-2420
Practice Address - Fax:970-826-2429
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6229207V00000X
WAOP61014771207V00000X
CO46656207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
133125100OtherFIRSTCARE & SW LIFE&HEALT
311819386790650000OtherTRICARE
TXP00070099OtherRAILROAD MEDICARE
TX159097801Medicaid
CO01936531Medicaid
7431448OtherAETNA
3277999OtherCIGNA
TX8J3940OtherBCBS
311819386790650000OtherTRICARE
TXP00070099OtherRAILROAD MEDICARE
3277999OtherCIGNA