Provider Demographics
NPI:1215919642
Name:ELLMAN, MATTHEW S (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:ELLMAN
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:PO BOX 208093
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8093
Mailing Address - Country:US
Mailing Address - Phone:203-785-3830
Mailing Address - Fax:203-785-2830
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:YPB, 3RD FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-7411
Practice Address - Fax:203-785-4194
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031869207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001318692Medicaid
CT110007647Medicare ID - Type Unspecified
F39210Medicare UPIN