Healthcare Provider Details

I. General information

NPI: 1174597934
Provider Name (Legal Business Name): JOE E ELLIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W 5TH ST
BENTON KY
42025-1123
US

IV. Provider business mailing address

PO BOX 256
BENTON KY
42025-0256
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-7421
  • Fax: 270-527-3118
Mailing address:
  • Phone: 270-527-7421
  • Fax: 270-527-3118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1073DT
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number1073DT
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: