Provider Demographics
NPI:1265404388
Name:ELLIS, DOUGLAS A (PHYSICAL THERAPIST)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:3233 W CHARLESTON BLVD
Practice Address - Street 2:STE 107
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1938
Practice Address - Country:US
Practice Address - Phone:702-258-9381
Practice Address - Fax:702-258-9584
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0149225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1265404388Medicaid
DL668ZOtherMEDICARE PTAN