Provider Demographics
NPI:1356341754
Name:ELLISON, EUGENE T JR (MD)
Entity type:Individual
Prefix:
First Name:EUGENE
Middle Name:T
Last Name:ELLISON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:5402 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-4607
Practice Address - Country:US
Practice Address - Phone:903-614-3937
Practice Address - Fax:903-614-3525
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9187207W00000X
ARC4704207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B87741Medicare UPIN
TX89E251Medicare ID - Type Unspecified