Provider Demographics
NPI:1245339977
Name:ELLMAN, MICHAEL GARY (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GARY
Last Name:ELLMAN
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 850304
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-0304
Mailing Address - Country:US
Mailing Address - Phone:972-682-3909
Mailing Address - Fax:972-682-9289
Practice Address - Street 1:2692 N GALLOWAY
Practice Address - Street 2:402
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2636
Practice Address - Country:US
Practice Address - Phone:972-682-3909
Practice Address - Fax:972-682-9289
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3092174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX12249902Medicaid
TXG14523Medicare UPIN
TX00538LMedicare ID - Type Unspecified
TX12249902Medicaid