Provider Demographics
NPI:1629162458
Name:ELLIS, LORA ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:LORA
Middle Name:ELIZABETH
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 REMICK BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-9168
Mailing Address - Country:US
Mailing Address - Phone:937-885-4475
Mailing Address - Fax:937-885-3670
Practice Address - Street 1:76 REMICK BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-9168
Practice Address - Country:US
Practice Address - Phone:937-885-4475
Practice Address - Fax:937-885-3670
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35086223208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2592690Medicaid