Healthcare Provider Details

I. General information

NPI: 1063507432
Provider Name (Legal Business Name): ELLIS JOHN CIVELLO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MESA VERDE DR E
CENTER POINT TX
78010-3548
US

IV. Provider business mailing address

230 MESA VERDE DR E
CENTER POINT TX
78010-3548
US

V. Phone/Fax

Practice location:
  • Phone: 830-460-6655
  • Fax:
Mailing address:
  • Phone: 830-634-2212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG7046
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: