Provider Demographics
NPI:1871540716
Name:ELLIS, MATTHEW S (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:ELLIS
Suffix:
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:PO BOX 3123
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3123
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6400 W NEWBERRY RD STE 104
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4399
Practice Address - Country:US
Practice Address - Phone:352-333-5918
Practice Address - Fax:352-333-4684
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96520207PE0005X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279886700Medicaid
FL56447OtherBCBS
FL279886700Medicaid
FLAB868ZMedicare PIN