Provider Demographics
NPI:1912068669
Name:ELLISON, DAVID WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WILLIAM
Last Name:ELLISON
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 1:262 DANNY THOMAS PL
Mailing Address - Street 2:MS 515
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-3678
Mailing Address - Country:US
Mailing Address - Phone:901-595-3006
Mailing Address - Fax:901-595-3842
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:901-595-3006
Practice Address - Fax:901-595-3842
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41696207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ220105Medicaid
MS03081001Medicaid
LA1409596Medicaid
OK200110020AMedicaid
AL009910542Medicaid
TN5441542Medicaid
NC7615993Medicaid