Provider Demographics
NPI:1629530225
Name:ELLIS, COLETTE MARK (MD)
Entity Type:Individual
Prefix:
First Name:COLETTE
Middle Name:MARK
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 1:1059 BAYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-2647
Mailing Address - Country:US
Mailing Address - Phone:713-339-0341
Mailing Address - Fax:
Practice Address - Street 1:1059 BAYWOOD DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-2647
Practice Address - Country:US
Practice Address - Phone:713-339-0341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS8030208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208600000XAllopathic & Osteopathic PhysiciansSurgery