Provider Demographics
NPI:1174626311
Name:ELLYN, NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:ELLYN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1707 OSAGE ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2611
Mailing Address - Country:US
Mailing Address - Phone:703-578-0100
Mailing Address - Fax:703-824-8357
Practice Address - Street 1:1707 OSAGE ST
Practice Address - Street 2:SUITE 205
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-2611
Practice Address - Country:US
Practice Address - Phone:703-578-0100
Practice Address - Fax:703-824-8357
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2010-05-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101027634207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006380883Medicaid
VA1174626311Medicaid
VAB93983Medicare UPIN
VA006380883Medicaid