Provider Demographics
NPI:1982680849
Name:ELLIS, BENTON R (MD)
Entity Type:Individual
Prefix:DR
First Name:BENTON
Middle Name:R
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 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:972-233-1999
Mailing Address - Fax:972-233-3666
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8020207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX128452304Medicaid
TX128452308OtherMEDICAID CSHCN
TX83841KOtherBCBS
TX128452303Medicaid
TX128452306Medicaid
TX128452307Medicaid
TX128452309OtherMEDICAID CSHCN
050065923OtherRAILROAD
TX128452310OtherMEDICAID CSHCN
TX83841KMedicare PIN
TX128452309OtherMEDICAID CSHCN
TX89073KMedicare PIN
TX83841KOtherBCBS
050065923OtherRAILROAD
TXTXB113488Medicare PIN