Provider Demographics
NPI:1215196985
Name:JOHNSON, ELLIS A (MD)
Entity Type:Individual
Prefix:
First Name:ELLIS
Middle Name:A
Last Name:JOHNSON
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 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:1 HARNOIS AVE
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4392
Practice Address - Country:US
Practice Address - Phone:207-662-1340
Practice Address - Fax:207-662-1341
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD18827207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH32000667Medicaid
ME002249502Medicare PIN
MEP00990377Medicare PIN
NH32000667Medicaid
ME002249501Medicare PIN
ME002249503Medicare PIN