Healthcare Provider Details

I. General information

NPI: 1093762908
Provider Name (Legal Business Name): CLYDE NEAL ELLIS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2435 FIRE MESA ST STE 110A
LAS VEGAS NV
89128-9009
US

IV. Provider business mailing address

2435 FIRE MESA ST # 110A
LAS VEGAS NV
89128-9009
US

V. Phone/Fax

Practice location:
  • Phone: 725-200-3242
  • Fax: 702-664-3242
Mailing address:
  • Phone: 702-853-3300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35220
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number19367
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR8884
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: