Provider Demographics
NPI:1992985782
Name:CARL RICHARD ELLIS DPM
Entity type:Organization
Organization Name:CARL RICHARD ELLIS DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-682-1778
Mailing Address - Street 1:416 JUNIPER DR
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-9223
Mailing Address - Country:US
Mailing Address - Phone:850-682-1778
Mailing Address - Fax:
Practice Address - Street 1:416 JUNIPER DR
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-9223
Practice Address - Country:US
Practice Address - Phone:850-682-1778
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3899620001Medicare NSC