Provider Demographics
NPI:1972215234
Name:ELLIS, GARY II
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:ELLIS
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:243 8TH AVE W APT 8
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-2541
Mailing Address - Country:US
Mailing Address - Phone:304-840-6328
Mailing Address - Fax:
Practice Address - Street 1:900 20TH ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25703-1810
Practice Address - Country:US
Practice Address - Phone:681-378-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist