Provider Demographics
NPI:1659682219
Name:ELLIS, MARK KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:KENNETH
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 5TH AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-8832
Mailing Address - Country:US
Mailing Address - Phone:914-393-2368
Mailing Address - Fax:
Practice Address - Street 1:2 5TH AVE APT 2D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-8832
Practice Address - Country:US
Practice Address - Phone:914-393-2368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-29
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72186207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services