Provider Demographics
NPI:1780635268
Name:ELLMAN, MARC (MD)
Entity Type:Individual
Prefix:DR
First Name:MARC
Middle Name:
Last Name:ELLMAN
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 1:4800 N 22ND ST STE 210
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4963
Mailing Address - Country:US
Mailing Address - Phone:915-267-2020
Mailing Address - Fax:915-595-4460
Practice Address - Street 1:1400 COMMON DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-5922
Practice Address - Country:US
Practice Address - Phone:915-595-4375
Practice Address - Fax:915-595-4460
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0199207W00000X
TXL8680207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17702003Medicaid
TX168080301Medicaid
TXI14335Medicare UPIN