Provider Demographics
NPI:1679595144
Name:ELLIS, BOBBY J (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:J
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:921 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1837
Practice Address - Country:US
Practice Address - Phone:580-223-5311
Practice Address - Fax:580-223-8227
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS0417821207R00000X
OK26021207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200128140AMedicaid
D09107Medicare UPIN
OK200128140AMedicaid