Provider Demographics
NPI:1720181951
Name:ELLEN, MARK I (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:I
Last Name:ELLEN
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 1:10435 SE 170TH PL
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8998
Mailing Address - Country:US
Mailing Address - Phone:352-630-6250
Mailing Address - Fax:
Practice Address - Street 1:2108 ALEXANDER CIR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30326-1246
Practice Address - Country:US
Practice Address - Phone:214-952-3501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA063613002081S0010X
PAMD051555L2081S0010X
NC2005-018262081S0010X
CAG713762081S0010X
FLME1450252081S0010X, 208100000X
GA505782081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF39320Medicare UPIN