Provider Demographics
NPI:1780785402
Name:ELLENS, DAVID L (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:ELLENS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 E HWY 50 STE B
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5189
Mailing Address - Country:US
Mailing Address - Phone:352-241-0549
Mailing Address - Fax:352-242-9325
Practice Address - Street 1:1735 E HWY 50 STE B
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5189
Practice Address - Country:US
Practice Address - Phone:352-241-0549
Practice Address - Fax:352-242-9325
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088924207R00000X
FLME156236207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088924Medicaid
FL115783900Medicaid
IL036088924Medicaid