Healthcare Provider Details

I. General information

NPI: 1780703561
Provider Name (Legal Business Name): MATTHEW S ELLIS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 W NEWBERRY RD SUITE 104
GAINESVILLE FL
32605
US

IV. Provider business mailing address

PO BOX 3123
ST AUGUSTINE FL
32085-3123
US

V. Phone/Fax

Practice location:
  • Phone: 352-333-5911
  • Fax: 353-333-4684
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0011X
TaxonomyUndersea and Hyperbaric Medicine (Preventive Medicine) Physician
License NumberME96520
License Number StateFL

VIII. Authorized Official

Name: DR. MATTHEW STEWART ELLIS
Title or Position: PRESIDENT
Credential: MD
Phone: 352-333-5911