Provider Demographics
NPI:1659551752
Name:PATRICK B ELLIS DO PC
Entity Type:Organization
Organization Name:PATRICK B ELLIS DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-701-5666
Mailing Address - Street 1:520 24TH AVE S.W.
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5106
Mailing Address - Country:US
Mailing Address - Phone:405-701-5666
Mailing Address - Fax:405-701-5667
Practice Address - Street 1:520 24TH AVE S.W.
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-5106
Practice Address - Country:US
Practice Address - Phone:405-701-5666
Practice Address - Fax:405-701-5667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3351174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100138180BMedicaid