Provider Demographics
NPI:1417947417
Name:ELLIS, JOHN L II (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:L
Last Name:ELLIS
Suffix:II
Gender:M
Credentials:OD
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Mailing Address - Street 1:3800 N MESA ST
Mailing Address - Street 2:STE B1
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1535
Mailing Address - Country:US
Mailing Address - Phone:915-533-1811
Mailing Address - Fax:915-533-3641
Practice Address - Street 1:3800 N MESA
Practice Address - Street 2:STE C8
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902
Practice Address - Country:US
Practice Address - Phone:915-533-1811
Practice Address - Fax:915-533-3641
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2016-10-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TX5395T6152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM06654720OtherMEDICAID
143852OtherCOLE VISION
4722920001OtherMEDICARE PALMETTO
TX160390401Medicaid
TX5395OtherEYEMED VISION
TX807829OtherBLUE CROSS BLUE SHIELD
914210OtherBLOCK VISION
P00113768OtherMEDICARE RAILROAD
TX5395OtherEYEMED VISION
P00113768OtherMEDICARE RAILROAD