Provider Demographics
NPI:1174514137
Name:ELLIS, DAVID DALE (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:DALE
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:720 PLEASANTON RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78214-1306
Mailing Address - Country:US
Mailing Address - Phone:210-921-3800
Mailing Address - Fax:210-921-6615
Practice Address - Street 1:720 PLEASANTON RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78214-1306
Practice Address - Country:US
Practice Address - Phone:210-921-3800
Practice Address - Fax:210-921-6615
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF3931207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX098614304Medicaid
TX8L15934Medicare PIN