Provider Demographics
NPI:1982647475
Name:ELLIS, CLARENCE V (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:V
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 1:2420 W 26TH AVE STE 400D
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5357
Mailing Address - Country:US
Mailing Address - Phone:303-988-4870
Mailing Address - Fax:303-984-1114
Practice Address - Street 1:12790 W ALAMEDA PKWY STE A
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-2850
Practice Address - Country:US
Practice Address - Phone:303-403-6350
Practice Address - Fax:303-403-6372
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO33692207Q00000X, 2083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0801103606OtherMEDICARE RAILROAD
CO61572578Medicaid
0801103606OtherMEDICARE RAILROAD
B04102Medicare UPIN