Provider Demographics
NPI:1790965416
Name:ELLIS, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
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 1:134 BIRCH HILL RD
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:CT
Mailing Address - Zip Code:06883-1710
Mailing Address - Country:US
Mailing Address - Phone:203-227-3929
Mailing Address - Fax:203-227-2947
Practice Address - Street 1:134 BIRCH HILL RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:CT
Practice Address - Zip Code:06883-1710
Practice Address - Country:US
Practice Address - Phone:203-227-3929
Practice Address - Fax:203-227-2947
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0378072085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology