Provider Demographics
NPI:1750494936
Name:ELLISON, DAVID F (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:F
Last Name:ELLISON
Suffix:
Gender:M
Credentials:DO
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 11225
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37401-2225
Mailing Address - Country:US
Mailing Address - Phone:423-892-9483
Mailing Address - Fax:423-899-0928
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2103
Practice Address - Country:US
Practice Address - Phone:423-778-7806
Practice Address - Fax:423-778-2360
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO00749207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3302285Medicaid
TN3031773OtherBLUE CROSS BLUE SHIELD OF TENNESSEE
NC890550MMedicaid
AL009602430Medicaid
GA000380047CMedicaid
TN050047705OtherMEDICARE RAILROAD
GA000380047CMedicaid
TN3302285Medicare ID - Type Unspecified
TN3302285Medicaid