Provider Demographics
NPI:1881768802
Name:ELLIS, GREGORY W (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:W
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 71312
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84171-0312
Mailing Address - Country:US
Mailing Address - Phone:801-878-4081
Mailing Address - Fax:801-432-4264
Practice Address - Street 1:7050 SOUTH HIGHLAND DRIVE
Practice Address - Street 2:SUITE 230
Practice Address - City:COTTONWOOD HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-878-4081
Practice Address - Fax:801-432-4264
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT178505-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry