Healthcare Provider Details

I. General information

NPI: 1851551790
Provider Name (Legal Business Name): SHAWN MICHAEL ELLIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4345 W MEMORIAL RD STE 110
OKLAHOMA CITY OK
73134-1717
US

IV. Provider business mailing address

4401 W MEMORIAL RD 140
OKLAHOMA CITY OK
73134-1785
US

V. Phone/Fax

Practice location:
  • Phone: 405-418-7000
  • Fax:
Mailing address:
  • Phone: 405-752-3162
  • Fax: 405-936-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number04757
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number04757
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: