Provider Demographics
NPI:1366887861
Name:ELLIS, KEISHA BONHOMME (MD)
Entity type:Individual
Prefix:
First Name:KEISHA
Middle Name:BONHOMME
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KEISHA
Other - Middle Name:
Other - Last Name:BONHOMME
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3225 N POINT PKWY STE 103
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4726
Mailing Address - Country:US
Mailing Address - Phone:470-657-3312
Mailing Address - Fax:833-450-5693
Practice Address - Street 1:3225 N POINT PKWY STE 103
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4726
Practice Address - Country:US
Practice Address - Phone:470-657-3312
Practice Address - Fax:833-450-5693
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA080549207RE0101X, 207R00000X
FLME154963207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism