Provider Demographics
NPI:1871570101
Name:ELLIS, KATHERINE L (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:L
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 1:1302 N STATE HIGHWAY 91
Mailing Address - Street 2:
Mailing Address - City:DENISON
Mailing Address - State:TX
Mailing Address - Zip Code:75020-1167
Mailing Address - Country:US
Mailing Address - Phone:903-465-1857
Mailing Address - Fax:903-327-8023
Practice Address - Street 1:1200 REBA MCENTIRE DR
Practice Address - Street 2:
Practice Address - City:DENISON
Practice Address - State:TX
Practice Address - Zip Code:75020-9057
Practice Address - Country:US
Practice Address - Phone:903-416-1025
Practice Address - Fax:903-327-8023
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3091207R00000X, 208100000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX099349501Medicaid
F74680Medicare UPIN
TX099349501Medicaid
TX00L77XMedicare PIN