Provider Demographics
NPI:1285748293
Name:ELLIS, JEFFREY IRA (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:IRA
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 1:358 S OYSTER BAY RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-3508
Mailing Address - Country:US
Mailing Address - Phone:516-822-7546
Mailing Address - Fax:516-937-7546
Practice Address - Street 1:358 S OYSTER BAY RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-3508
Practice Address - Country:US
Practice Address - Phone:516-822-7546
Practice Address - Fax:516-937-7546
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234545207N00000X, 207ND0101X, 207NP0225X
NY234545-01207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI72909Medicare UPIN
NY4K154ZVQT1Medicare PIN