MEDICARE: CLYDE NEAL ELLIS JR. MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	35220	WV
2	208C00000X	Colon & Rectal Surgery Physician	19367	NV
3	208600000X	Surgery Physician	R8884	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093762908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLYDE NEAL ELLIS JR. MD

Provider Business Mailing Address
First Line	:	2435 FIRE MESA ST
Second Line	:	# 110A
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-9009
Country	:	US
Telephone Number	:	702-853-3300
Fax Number	:

Provider Business Practice Location Address
First Line	:	2435 FIRE MESA ST STE 110A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-9009
Country	:	US
Telephone Number	:	725-200-3242
Fax Number	:	702-664-3242

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	07/10/2025

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