Provider Demographics
NPI:1033671359
Name:ELLIS, JONATHAN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:DAVID
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 1:231 ALBERT SABIN WAY RM 5502
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45267-0212
Mailing Address - Country:US
Mailing Address - Phone:513-558-4592
Mailing Address - Fax:513-558-2220
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-558-4592
Practice Address - Fax:513-558-2220
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-04
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program