Provider Demographics
NPI:1740297811
Name:ELLIS, PAUL DEVERE (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:DEVERE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:11459 JOHNS CREEK PKWY
Mailing Address - Street 2:STE 250
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30097-3517
Mailing Address - Country:US
Mailing Address - Phone:770-497-1555
Mailing Address - Fax:770-497-9998
Practice Address - Street 1:11459 JOHNS CREEK PKWY
Practice Address - Street 2:STE 250
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-3517
Practice Address - Country:US
Practice Address - Phone:770-497-1555
Practice Address - Fax:770-497-9998
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2016-05-05
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA041549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00701918BMedicaid
GA00701918BMedicaid
G09860Medicare UPIN