Provider Demographics
NPI:1609943174
Name:ELLIS, STANLEY BRENT (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:BRENT
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 1:1519 W KEENE RD
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32703-8416
Mailing Address - Country:US
Mailing Address - Phone:407-880-0439
Mailing Address - Fax:
Practice Address - Street 1:1519 W KEENE RD
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32703-8416
Practice Address - Country:US
Practice Address - Phone:407-880-0439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 56698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE78978Medicare UPIN