Provider Demographics
NPI:1023026069
Name:ELLIE, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ELLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:338 HARRIS HILL RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7470
Mailing Address - Country:US
Mailing Address - Phone:716-634-4798
Mailing Address - Fax:716-634-0987
Practice Address - Street 1:338 HARRIS HILL RD
Practice Address - Street 2:SUITE 207
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7470
Practice Address - Country:US
Practice Address - Phone:716-634-4798
Practice Address - Fax:716-634-0987
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY142491-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00808080Medicaid
NYD01755Medicare UPIN
NY00808080Medicaid