Provider Demographics
NPI:1891792214
Name:ELLIS, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
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 1:2 COATES DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-6758
Mailing Address - Country:US
Mailing Address - Phone:845-651-1400
Mailing Address - Fax:845-651-1512
Practice Address - Street 1:70 HATFIELD LN
Practice Address - Street 2:STE 204
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6735
Practice Address - Country:US
Practice Address - Phone:845-291-1260
Practice Address - Fax:845-294-2312
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180343207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
18N881L663OtherMEDICARE
NY01852446Medicaid
NY01852446Medicaid