Provider Demographics
NPI:1154307601
Name:ELLIS, JOHN ARTHUR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ARTHUR
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:934-619-4366
Practice Address - Street 1:600 N PICKAWAY ST
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-1447
Practice Address - Country:US
Practice Address - Phone:740-474-2126
Practice Address - Fax:740-477-1022
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-6876207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2372838Medicaid
OH000000372264OtherBLUE CROSS BLUE SHIELD
OH2372838Medicaid
OH000000372264OtherBLUE CROSS BLUE SHIELD
OHD33613Medicare UPIN
OH0855622Medicare PIN