Basic Information
| Provider Information | |||||||||
| NPI: | 1891792214 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 COATES DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456511400 | ||||||||
| FaxNumber: | 8456511512 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 HATFIELD LN | ||||||||
| Address2: | STE 204 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452911260 | ||||||||
| FaxNumber: | 8452942312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2005 | ||||||||
| LastUpdateDate: | 09/27/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 180343 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 18N881L663 | 01 | MEDICARE | OTHER | 01852446 | 05 | NY | MEDICAID |