Provider Demographics
NPI:1043384795
Name:ELLIS, JOHN P (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21992 LORAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW PARK
Mailing Address - State:OH
Mailing Address - Zip Code:44126-3333
Mailing Address - Country:US
Mailing Address - Phone:440-333-7300
Mailing Address - Fax:440-995-1234
Practice Address - Street 1:21992 LORAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-3333
Practice Address - Country:US
Practice Address - Phone:440-333-7300
Practice Address - Fax:440-995-1234
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002463E213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0691845Medicaid
6097820001Medicare NSC
OH0691845Medicaid
OH0607228Medicare PIN