Healthcare Provider Details

I. General information

NPI: 1407340441
Provider Name (Legal Business Name): KELVIN ELLIS JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2018
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 MAIN ST
ZACHARY LA
70791-4037
US

IV. Provider business mailing address

3600 FORBES AVE
PITTSBURGH PA
15213-3410
US

V. Phone/Fax

Practice location:
  • Phone: 225-658-4316
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number346884
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number315779
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: