Provider Demographics
NPI:1447448865
Name:ELLIS, DIANE ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:ELIZABETH
Last Name:ELLIS
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:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9419
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:701-234-2345
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT365485-1205207V00000X
NDPT21592208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology