Provider Demographics
NPI:1811907561
Name:ELLIS, ARTHUR H III (OD)
Entity type:Individual
Prefix:
First Name:ARTHUR
Middle Name:H
Last Name:ELLIS
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 PEACHTREE PLZ
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-2500
Mailing Address - Country:US
Mailing Address - Phone:731-772-2020
Mailing Address - Fax:731-772-3954
Practice Address - Street 1:140 PEACHTREE PLZ
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-2500
Practice Address - Country:US
Practice Address - Phone:731-772-2020
Practice Address - Fax:731-772-3954
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD0000000613152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0149285OtherBLUECROSS BLUESHIELD
TN3593820Medicaid
TNP00270315OtherRAILROAD MEDICARE
TNP00270315OtherRAILROAD MEDICARE
TN3593820Medicare PIN
TN3593820Medicaid