Provider Demographics
NPI:1174597934
Name:ELLIS, JOE E (OD)
Entity type:Individual
Prefix:DR
First Name:JOE
Middle Name:E
Last Name:ELLIS
Suffix:
Gender:M
Credentials:OD
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 256
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-0256
Mailing Address - Country:US
Mailing Address - Phone:270-527-7421
Mailing Address - Fax:270-527-3118
Practice Address - Street 1:109 W 5TH ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-1123
Practice Address - Country:US
Practice Address - Phone:270-527-7421
Practice Address - Fax:270-527-3118
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1073DT152W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY149794OtherHEALTHLINK
KY77010734Medicaid
KY000000053519OtherBLUE CROSS BLUE SHIELD
KY4349131OtherAETNA
KYT54572OtherBLUEGRASS FAMILY HEALTH
KYT54572OtherBLUEGRASS FAMILY HEALTH
KYT54572Medicare UPIN
KY4349131OtherAETNA
KYME0212681OtherDEA