Provider Demographics
NPI:1811196215
Name:ELLIS, GILLIAN A (MD)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 DON WICKHAM DR
Mailing Address - Street 2:MP SL ADMIN
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1979
Mailing Address - Country:US
Mailing Address - Phone:352-536-8840
Mailing Address - Fax:352-536-8841
Practice Address - Street 1:1900 DON WICKHAM DR
Practice Address - Street 2:MP SL ADMIN
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1979
Practice Address - Country:US
Practice Address - Phone:352-536-8840
Practice Address - Fax:352-536-8841
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062791207R00000X
FLME107435207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003163400Medicaid
FLME107435OtherMEDICAL LICENSE
FL003163400Medicaid