Provider Demographics
NPI:1285631242
Name:ELLIS, JOHN WILLIAM (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLIAM
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 1:6320 W UNION HILLS DR STE 2800B
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1380
Mailing Address - Country:US
Mailing Address - Phone:623-322-4991
Mailing Address - Fax:623-322-9568
Practice Address - Street 1:6320 W UNION HILLS DR STE 2800B
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1380
Practice Address - Country:US
Practice Address - Phone:623-322-4991
Practice Address - Fax:623-322-9568
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3881207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ7448458OtherAETNA
AZ81060639685308A002OtherCHAMPUS
AZ922345OtherUSA
AZ2Z0278OtherHEALTH NET
AZ5469474OtherCCN
AZ783789Medicaid
AZ81060639601OtherPACIFICARE
AZ56VMVZOtherUHC
AZ2024711OtherCIGNA
AZ2103583OtherFIRST HEALTH
AZAZ0733980OtherBC/BS
AZPROV000061230OtherSCHALLER ANDERSON
AZ2Z0278OtherHEALTH NET
AZ56VMVZOtherUHC
AZ81060639685308A002OtherCHAMPUS