Healthcare Provider Details

I. General information

NPI: 1538698543
Provider Name (Legal Business Name): JEFFREY LEE ELLIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 11/30/2025
Certification Date: 11/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 VFW PKWY # 112
WEST ROXBURY MA
02132-4927
US

IV. Provider business mailing address

1400 VFW PKWY # 112
WEST ROXBURY MA
02132-4927
US

V. Phone/Fax

Practice location:
  • Phone: 857-203-6205
  • 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 NumberMT212656
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMT212656
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number036.160253
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: