Provider Demographics
NPI:1861455719
Name:ELLIS, STEPHEN RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:RICHARD
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:PO BOX 650823 DEPT 41197
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0823
Mailing Address - Country:US
Mailing Address - Phone:800-411-7515
Mailing Address - Fax:
Practice Address - Street 1:3625 N HALL ST STE 800
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-5106
Practice Address - Country:US
Practice Address - Phone:214-252-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0712207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXI31131Medicare UPIN