| Doctor Name: | DR. ROBERT RAY ELLIS |
| NPI Number: | 1881945566 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | DPT |
| License Number: | PT5070 |
| Business Practice Address: | 10194 Cottage Ct Diberville, MS - 395404744 |
| Business Phone Number: | 2283261115 |
| Business Fax Number: | |
| Mailing Address: | 10194 Cottage Ct, DIBERVILLE |
| State: | MS |
| Postal Code: | 395404744 |
| Phone Number: | 2283261115 |
| Fax Number: | |
| NPI Enumeration Date: | 09/21/2012 |
| NPI Last Update Date: | 09/21/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171000000X |
| License Number: | PT5070 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MS |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Military Health Care Provider |
| Taxonomy Specialization: | |
| Taxonomy Definition: | Active duty military health care providers not otherwise classified who need to be separately identified for operational, clinical, or administrative processes. |