Provider Demographics
NPI:1962658989
Name:ELLIS, DUSTIN CLAY (MD)
Entity Type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:CLAY
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 230
Mailing Address - Street 2:2229 MARY SHERMAN DRIVE
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-0230
Mailing Address - Country:US
Mailing Address - Phone:812-268-3318
Mailing Address - Fax:812-268-4017
Practice Address - Street 1:2186 N HOSPITAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7654
Practice Address - Country:US
Practice Address - Phone:812-268-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-11
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013685A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200015680AMedicaid
IN200015680AMedicaid