Provider Demographics
NPI:1699781948
Name:ELLISON, RICHARD B JR (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:B
Last Name:ELLISON
Suffix:JR
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:PO BOX 55769
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39296-5769
Mailing Address - Country:US
Mailing Address - Phone:601-200-6162
Mailing Address - Fax:
Practice Address - Street 1:969 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4606
Practice Address - Country:US
Practice Address - Phone:877-406-2916
Practice Address - Fax:601-982-7909
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS121082085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113408Medicaid
1861428351OtherGROUP NPI
1861428351OtherGROUP NPI
1861428351OtherGROUP NPI