Provider Demographics
NPI:1811934268
Name:DR MARK F ELLIS DPMA PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:DR MARK F ELLIS DPMA PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:337-593-1278
Mailing Address - Street 1:501 W SAINT MARY BLVD
Mailing Address - Street 2:STE 520
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4600
Mailing Address - Country:US
Mailing Address - Phone:337-593-1278
Mailing Address - Fax:337-593-1280
Practice Address - Street 1:913 S COLLEGE RD STE 216B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3060
Practice Address - Country:US
Practice Address - Phone:337-593-1278
Practice Address - Fax:337-593-1280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1670511213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1670511Medicaid
LA1098790001Medicare NSC
LA5CA19Medicare PIN