Provider Demographics
NPI:1972986693
Name:ELLIS, MICHAEL JOSEPH (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4057 ASBURY AVE STE 21
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-7700
Mailing Address - Country:US
Mailing Address - Phone:848-217-2662
Mailing Address - Fax:
Practice Address - Street 1:4057 ASBURY AVE STE 21
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753-7700
Practice Address - Country:US
Practice Address - Phone:848-217-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-30
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD11671208M00000X
NJ25MB10268400207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist