Healthcare Provider Details

I. General information

NPI: 1891792214
Provider Name (Legal Business Name): DAVID J ELLIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 HATFIELD LN STE 204
GOSHEN NY
10924-6735
US

IV. Provider business mailing address

2 COATES DR
GOSHEN NY
10924-6758
US

V. Phone/Fax

Practice location:
  • Phone: 845-291-1260
  • Fax: 845-294-2312
Mailing address:
  • Phone: 845-651-1400
  • Fax: 845-651-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number180343
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: