Provider Demographics
NPI:1700046273
Name:ELLIS, BRIAN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:THOMAS
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 1:500 E ROBINSON ST
Mailing Address - Street 2:STE 2600
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6697
Mailing Address - Country:US
Mailing Address - Phone:405-364-6432
Mailing Address - Fax:405-364-0090
Practice Address - Street 1:500 E ROBINSON ST
Practice Address - Street 2:STE 2600
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6697
Practice Address - Country:US
Practice Address - Phone:405-364-6432
Practice Address - Fax:405-364-0090
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26325208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200244680AMedicaid