Provider Demographics
NPI:1760478150
Name:ELLIS, DAVID S (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:S
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:PO BOX 120549
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-0549
Mailing Address - Country:US
Mailing Address - Phone:817-303-4521
Mailing Address - Fax:817-417-1100
Practice Address - Street 1:801 W I-20
Practice Address - Street 2:STE 1
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5851
Practice Address - Country:US
Practice Address - Phone:817-784-0818
Practice Address - Fax:817-417-1100
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3327208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128134702Medicaid
TX128134704Medicaid
TX128134702Medicaid
TX83Z606Medicare PIN
TX8036J9Medicare PIN