Provider Demographics
NPI:1376713586
Name:ELLISON, JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ELLISON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5421 S 1900 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-2908
Mailing Address - Country:US
Mailing Address - Phone:801-825-9703
Mailing Address - Fax:
Practice Address - Street 1:5421 S 1900 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-2908
Practice Address - Country:US
Practice Address - Phone:801-825-9703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6617396-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist