Provider Demographics
NPI:1205809050
Name:ELLIS, EARL ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:ANTHONY
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 1:66 RUTLAND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5313
Mailing Address - Country:US
Mailing Address - Phone:718-282-4412
Mailing Address - Fax:718-856-8055
Practice Address - Street 1:66 RUTLAND RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-5313
Practice Address - Country:US
Practice Address - Phone:718-282-4412
Practice Address - Fax:718-856-8055
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-10
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149280207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY149280OtherSTATE LICENSE NUMBER
09E611Medicare ID - Type Unspecified
NY149280OtherSTATE LICENSE NUMBER