Provider Demographics
NPI:1427076488
Name:MINTON, ELLIS L (MD)
Entity type:Individual
Prefix:
First Name:ELLIS
Middle Name:L
Last Name:MINTON
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 1:709 W LEUDA ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3115
Mailing Address - Country:US
Mailing Address - Phone:817-926-2511
Mailing Address - Fax:817-924-0167
Practice Address - Street 1:709 W LEUDA ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3115
Practice Address - Country:US
Practice Address - Phone:817-926-2511
Practice Address - Fax:817-924-0167
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3064207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology