Provider Demographics
NPI:1881988582
Name:ELLIS, CLAYTON TYLER (MD)
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:TYLER
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:502-588-0326
Practice Address - Street 1:ULP COLORECTAL SURGERY
Practice Address - Street 2:401 EAST CHESTNUT STREET, #710
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-5707
Practice Address - Country:US
Practice Address - Phone:502-583-8303
Practice Address - Fax:502-588-9506
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-31
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC173420390200000X
KYTP364208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program