Provider Demographics
NPI:1215975891
Name:ELLIS, MARK (DPM)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W SAINT MARY BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4600
Mailing Address - Country:US
Mailing Address - Phone:337-593-1278
Mailing Address - Fax:337-593-1280
Practice Address - Street 1:501 W SAINT MARY BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4600
Practice Address - Country:US
Practice Address - Phone:337-593-1278
Practice Address - Fax:337-593-1280
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA1670511213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1670511Medicaid
LA1670511Medicaid
LA5W546CA19Medicare PIN