Provider Demographics
NPI:1013063445
Name:ELLIS, HOWARD ROSS (MD)
Entity Type:Individual
Prefix:
First Name:HOWARD
Middle Name:ROSS
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 1170
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-1170
Mailing Address - Country:US
Mailing Address - Phone:470-325-0159
Mailing Address - Fax:470-325-0191
Practice Address - Street 1:665 DULUTH HWY STE 920
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046
Practice Address - Country:US
Practice Address - Phone:678-312-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50159208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000908432AMedicaid