Provider Demographics
NPI:1619646171
Name:ELLIS, EVAN LAWTON (DC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:LAWTON
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 KENILWORTH DR # 106
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2139
Mailing Address - Country:US
Mailing Address - Phone:443-901-4200
Mailing Address - Fax:
Practice Address - Street 1:1122 KENILWORTH DR STE 109
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2141
Practice Address - Country:US
Practice Address - Phone:443-901-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-08
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS04102111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor