Provider Demographics
NPI:1740266451
Name:ELLIS, NITZA F (MD)
Entity type:Individual
Prefix:DR
First Name:NITZA
Middle Name:F
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14209-1603
Mailing Address - Country:US
Mailing Address - Phone:716-884-0230
Mailing Address - Fax:716-884-2415
Practice Address - Street 1:1131 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14209-1603
Practice Address - Country:US
Practice Address - Phone:716-884-0230
Practice Address - Fax:716-884-2415
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1379512080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00010050901OtherUNIVERA
NY01029556Medicaid
NY1206842OtherINDEPENDENT HEALTH ASSOC