Provider Demographics
NPI:1659411080
Name:ELLIS, DAVID PAUL (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:SHELDON
Practice Address - State:IA
Practice Address - Zip Code:51201-1235
Practice Address - Country:US
Practice Address - Phone:712-324-6366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI243720202085R0202X
MN510952085R0202X
SD79362085R0202X
IA394132085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI24372020OtherMEDICAL LICENSE
AZ23836OtherMEDICAL LICENSE
MN435448000Medicaid
MN435448000Medicaid
B52618Medicare UPIN