Provider Demographics
NPI:1952393175
Name:ELLIS, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:315 S MANNING BLVD
Mailing Address - Street 2:MEDICAL IMAGING DEPARTMENT
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12208-1707
Mailing Address - Country:US
Mailing Address - Phone:518-525-1852
Mailing Address - Fax:518-525-1559
Practice Address - Street 1:315 S MANNING BLVD
Practice Address - Street 2:MEDICAL IMAGING DEPARTMENT
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-1707
Practice Address - Country:US
Practice Address - Phone:518-525-1852
Practice Address - Fax:518-525-1559
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2012-05-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1446722085N0904X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00797791Medicaid
NY00797791Medicaid
NYRA2935Medicare PIN