Provider Demographics
NPI:1043342322
Name:ELLIS, DUNK A III (MD)
Entity type:Individual
Prefix:
First Name:DUNK
Middle Name:A
Last Name:ELLIS
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563-5108
Mailing Address - Country:US
Mailing Address - Phone:228-474-2212
Mailing Address - Fax:228-475-6271
Practice Address - Street 1:3736 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-5108
Practice Address - Country:US
Practice Address - Phone:228-474-2212
Practice Address - Fax:228-475-6271
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS12710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00113221Medicaid
MS00113221Medicaid
MS080001855Medicare ID - Type Unspecified