MEDICARE: DR. CHRISTIAN ELLIS D.O.

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	204D00000X	Neuromusculoskeletal Medicine & OMM Physician	3660	OK
2	208600000X	Surgery Physician	3660	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00690379	OTHER		RR MEDICARE

Other Identifiers

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

General Provider Information

NPI Number	:	1205832607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISTIAN ELLIS D.O.

Provider Business Mailing Address
First Line	:	4401 W MEMORIAL RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-1785
Country	:	US
Telephone Number	:	405-749-4231
Fax Number	:	405-749-4234

Provider Business Practice Location Address
First Line	:	4140 W MEMORIAL RD
Second Line	:	STE. 621
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-8366
Country	:	US
Telephone Number	:	405-749-4231
Fax Number	:	405-749-4234

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	01/31/2018

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Directions to “ DR. CHRISTIAN ELLIS D.O.” Practice Location

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