Provider Demographics
NPI:1790050128
Name:ELLIS, WILLIAM D (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:D
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PRESBYTERIAN HEALTHCARE SERVICES - PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:8300 CONSTITUTION AVE NE
Practice Address - Street 2:PMG EMERGENCY MEDICINE
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7613
Practice Address - Country:US
Practice Address - Phone:505-291-2122
Practice Address - Fax:505-291-2979
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2015-0028207P00000X
NM390200000390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program