Provider Demographics
NPI:1043239072
Name:ELLISON, RICHARD R (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:R
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PARK WEST BLVD
Mailing Address - Street 2:STE 150
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320
Mailing Address - Country:US
Mailing Address - Phone:330-864-8060
Mailing Address - Fax:330-864-8074
Practice Address - Street 1:1 PARK WEST BLVD
Practice Address - Street 2:STE 150
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320
Practice Address - Country:US
Practice Address - Phone:330-864-8060
Practice Address - Fax:330-864-8074
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055055207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0689054Medicaid
000000126056OtherANTHEM
0612361Medicare ID - Type Unspecified
OH0689054Medicaid