Healthcare Provider Details

I. General information

NPI: 1104986405
Provider Name (Legal Business Name): RODNEY LANE ELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9811 GREENBELT RD SUITE 104
LANHAM MD
20706-2215
US

IV. Provider business mailing address

9811 GREENBELT RD SUITE 104
LANHAM MD
20706-2215
US

V. Phone/Fax

Practice location:
  • Phone: 301-552-3953
  • Fax: 301-552-3957
Mailing address:
  • Phone: 301-552-3953
  • Fax: 301-552-3957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0021326
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: