Provider Demographics
NPI:1427066083
Name:ELLINGSON, THOMAS LEE (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:LEE
Last Name:ELLINGSON
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 1:501 S 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3550
Mailing Address - Country:US
Mailing Address - Phone:509-494-6700
Mailing Address - Fax:509-573-6275
Practice Address - Street 1:1806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2473
Practice Address - Country:US
Practice Address - Phone:509-452-4520
Practice Address - Fax:509-452-5224
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16492207R00000X
WAMD00029906207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120845Medicaid
WA2041412Medicaid
WA1427066083Medicaid
MS00120845Medicaid
MS110001594Medicare ID - Type Unspecified