Basic Information
| Provider Information | |||||||||
| NPI: | 1730751454 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARC ELLMAN, M.D., P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 COMMON DR | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799365922 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152672020 | ||||||||
| FaxNumber: | 9152674460 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 SATURN CIR | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880127727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152672020 | ||||||||
| FaxNumber: | 9155954460 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2021 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | MONIQUE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4012568382 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MARC ELLMAN, M.D., P.A. | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.