Provider Demographics
NPI:1477658094
Name:ELLEN, JONATHAN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:D
Last Name:ELLEN
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:PO BOX 1000 DEPT 0420
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0420
Mailing Address - Country:US
Mailing Address - Phone:901-484-2052
Mailing Address - Fax:901-507-8298
Practice Address - Street 1:4441 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8267
Practice Address - Country:US
Practice Address - Phone:901-484-2052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN26906208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4035038OtherBLUE CROSS
TN3092947Medicaid
TN3092947Medicaid
TN4035038OtherBLUE CROSS