Provider Demographics
NPI:1285620211
Name:ELLISON, SUZANNE E (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:E
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:
Other - Last Name:ELLISON MD PA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 W WINDCREST ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-4408
Mailing Address - Country:US
Mailing Address - Phone:830-997-0330
Mailing Address - Fax:830-997-7601
Practice Address - Street 1:200 W WINDCREST ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4408
Practice Address - Country:US
Practice Address - Phone:830-997-0330
Practice Address - Fax:830-997-7601
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00628708OtherMEDICARE RR
TX097503903Medicaid
TX8AQ211OtherBCBSTX
B22518Medicare UPIN
TX097503903Medicaid