Provider Demographics
NPI:1780630913
Name:ELLIS, LINDA SUZANNE (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:SUZANNE
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:SUZANNE
Other - Last Name:ELLIS-LASKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:440 RAYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79905-1613
Mailing Address - Country:US
Mailing Address - Phone:915-215-4480
Mailing Address - Fax:915-215-5386
Practice Address - Street 1:4845 ALAMEDA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905-2705
Practice Address - Country:US
Practice Address - Phone:915-215-4956
Practice Address - Fax:915-215-4770
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100038207ZP0102X, 207ZP0213X
TXS9678207ZP0213X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0213XAllopathic & Osteopathic PhysiciansPathologyPediatric Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology