Provider Demographics
NPI:1891706214
Name:ENNIS, DUANE (R, CT)
Entity Type:Individual
Prefix:
First Name:DUANE
Middle Name:
Last Name:ENNIS
Suffix:
Gender:M
Credentials:R, CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 CANTERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BONAIRE
Mailing Address - State:GA
Mailing Address - Zip Code:31005-3363
Mailing Address - Country:US
Mailing Address - Phone:478-918-0419
Mailing Address - Fax:
Practice Address - Street 1:1504 HARDEMAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1416
Practice Address - Country:US
Practice Address - Phone:478-745-3135
Practice Address - Fax:478-745-3136
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
364369247100000X, 2471C3401X, 2471C3402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Not Answered2471C3401XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistComputed Tomography
Not Answered2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography