Provider Demographics
NPI:1689644544
Name:ELLIS, WILLIAM G (DC, IME)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:G
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DC, IME
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 N COMMERCE ST
Mailing Address - Street 2:STE # 103
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1356
Mailing Address - Country:US
Mailing Address - Phone:580-223-4858
Mailing Address - Fax:
Practice Address - Street 1:2400 N COMMERCE ST
Practice Address - Street 2:STE # 103
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1356
Practice Address - Country:US
Practice Address - Phone:580-223-4858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2010-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1596111N00000X
KY3175111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKJ4318892452Medicaid
OKQDBMMMedicare ID - Type Unspecified