Provider Demographics
NPI:1124311162
Name:ELLIS, ANTHONY JEROME (CP)
Entity type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:JEROME
Last Name:ELLIS
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3729
Mailing Address - Country:US
Mailing Address - Phone:909-982-3434
Mailing Address - Fax:
Practice Address - Street 1:923 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3729
Practice Address - Country:US
Practice Address - Phone:909-982-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management