Provider Demographics
NPI:1992790786
Name:ELLIS, DOUGLAS R (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:R
Last Name:ELLIS
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:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61803-6002
Mailing Address - Country:US
Mailing Address - Phone:217-326-8630
Mailing Address - Fax:
Practice Address - Street 1:1002 MEDICAL CENTER DR
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-2116
Practice Address - Country:US
Practice Address - Phone:217-762-2518
Practice Address - Fax:217-762-5261
Is Sole Proprietor?:No
Enumeration Date:2005-09-17
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-081822207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE94405Medicare UPIN
IL455280Medicare ID - Type Unspecified