Provider Demographics
NPI:1336215599
Name:ELLIS, SHARON KELLY (OD)
Entity Type:Individual
Prefix:DR
First Name:SHARON
Middle Name:KELLY
Last Name:ELLIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4173 PROVIDENCE LN
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2629
Mailing Address - Country:US
Mailing Address - Phone:678-937-1622
Mailing Address - Fax:678-937-1627
Practice Address - Street 1:5370 STONE MOUNTAIN HWY
Practice Address - Street 2:SUITE 700
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3581
Practice Address - Country:US
Practice Address - Phone:770-879-1961
Practice Address - Fax:770-879-9872
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1283152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA41ZCFXKMedicare ID - Type Unspecified
GAU26696Medicare UPIN