Provider Demographics
NPI:1295742120
Name:ENNIS, CRAIG A (MD)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:A
Last Name:ENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:647 DUNLOP LN
Mailing Address - Street 2:210
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-5165
Mailing Address - Country:US
Mailing Address - Phone:931-502-3810
Mailing Address - Fax:931-502-3815
Practice Address - Street 1:647 DUNLOP LN
Practice Address - Street 2:210
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-5165
Practice Address - Country:US
Practice Address - Phone:931-502-3810
Practice Address - Fax:931-502-3815
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG72693207RG0100X
TN54629207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G726930Medicaid
CA00G726930Medicaid
CAWG72693HMedicare PIN