Provider Demographics
NPI:1750309878
Name:ELLIS, PAUL ROSCOE III (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:ROSCOE
Last Name:ELLIS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3600 GASTON AVE STE 450
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1904
Mailing Address - Country:US
Mailing Address - Phone:214-823-5351
Mailing Address - Fax:214-823-2825
Practice Address - Street 1:3600 GASTON AVE STE 450
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1904
Practice Address - Country:US
Practice Address - Phone:214-823-5351
Practice Address - Fax:214-823-2825
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3329174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD65098Medicare UPIN
TX82X932Medicare ID - Type Unspecified