Provider Demographics
NPI:1134162522
Name:ELLIS, DANIEL THOMAS (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
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 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:18 LAUREL RD E
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1327
Practice Address - Country:US
Practice Address - Phone:856-346-7816
Practice Address - Fax:856-346-6385
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA78633207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0068489Medicaid
NJ092794Medicare ID - Type Unspecified
NJ0068489Medicaid
NJ092794UKEMedicare PIN
NJ092794ZEDBMedicare PIN
I34853Medicare UPIN