Provider Demographics
NPI:1205903556
Name:ELLISON, INGRID A (MD)
Entity type:Individual
Prefix:DR
First Name:INGRID
Middle Name:A
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:4795 JIMMY LEE SMITH PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-2792
Mailing Address - Country:US
Mailing Address - Phone:770-222-6362
Mailing Address - Fax:866-528-7115
Practice Address - Street 1:4795 JIMMY LEE SMITH PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-2792
Practice Address - Country:US
Practice Address - Phone:770-222-6362
Practice Address - Fax:866-528-7115
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA45207152W00000X, 156FX1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAHO3376Medicare UPIN