Provider Demographics
NPI:1780652396
Name:ELLIS, OREN HENRY (MD)
Entity type:Individual
Prefix:
First Name:OREN
Middle Name:HENRY
Last Name:ELLIS
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 1:455 SAINT MICHAELS DR
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-7601
Mailing Address - Country:US
Mailing Address - Phone:505-820-5227
Mailing Address - Fax:
Practice Address - Street 1:1631 HOSPITAL DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4728
Practice Address - Country:US
Practice Address - Phone:505-424-0578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM66-2207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PROVO13053OtherMOLINA
5421393OtherCCN
10003858OtherLOVELACE
NMV7059Medicaid
NMNM01VP02OtherBCBS NM
2335644OtherUHC
NMV7059Medicaid