Provider Demographics
NPI:1851551790
Name:ELLIS, SHAWN MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:140
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-752-3162
Mailing Address - Fax:405-936-5211
Practice Address - Street 1:4345 W MEMORIAL RD STE 110
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1717
Practice Address - Country:US
Practice Address - Phone:405-418-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK04757208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine