Provider Demographics
NPI:1952708364
Name:ELLIS, ELLEN (DO)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:ELLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 PARK AVE
Mailing Address - Street 2:#12B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-2557
Mailing Address - Country:US
Mailing Address - Phone:516-650-8444
Mailing Address - Fax:
Practice Address - Street 1:67 PARK AVE
Practice Address - Street 2:#12B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2557
Practice Address - Country:US
Practice Address - Phone:516-650-8444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-01
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154539207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine