Provider Demographics
NPI:1366433898
Name:ELLISTON, WINSTON LEON (MD)
Entity type:Individual
Prefix:
First Name:WINSTON
Middle Name:LEON
Last Name:ELLISTON
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:DEPT 453 PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:14 MCDOWELL ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28801-4104
Practice Address - Country:US
Practice Address - Phone:828-255-3749
Practice Address - Fax:828-254-9925
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21399207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC202157FOtherMEDICARE PTAN
NC1366433898Medicaid
NC7930645Medicaid
202157AMedicare ID - Type Unspecified