Provider Demographics
NPI:1780009027
Name:ELLIS, DEMETRIUS J I
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:J
Last Name:ELLIS
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-4526
Mailing Address - Country:US
Mailing Address - Phone:405-632-0870
Mailing Address - Fax:918-878-7872
Practice Address - Street 1:2001 S GARNETT RD STE G
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-1838
Practice Address - Country:US
Practice Address - Phone:918-878-7877
Practice Address - Fax:918-878-7882
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator