Provider Demographics
NPI:1710949607
Name:ELLIS, LAURETTE M (MD)
Entity Type:Individual
Prefix:
First Name:LAURETTE
Middle Name:M
Last Name:ELLIS
Suffix:
Gender:F
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:PO BOX 558750
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33255-8750
Mailing Address - Country:US
Mailing Address - Phone:305-663-8409
Mailing Address - Fax:305-663-8573
Practice Address - Street 1:3100 SW 62 AVENUE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-663-8409
Practice Address - Fax:305-663-8573
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45097207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL96584ZMedicare ID - Type Unspecified
D63909Medicare UPIN