Provider Demographics
NPI:1184711426
Name:ELLIS, DAVID A (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:A
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 1:2530 NE KRESKY AVE STE C
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-2406
Mailing Address - Country:US
Mailing Address - Phone:360-996-4028
Mailing Address - Fax:360-996-4698
Practice Address - Street 1:2530 NE KRESKY AVE STE C
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-2406
Practice Address - Country:US
Practice Address - Phone:360-996-4028
Practice Address - Fax:360-996-4698
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00028509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1108828Medicaid
A46189Medicare UPIN
WAAB13934Medicare ID - Type Unspecified