Provider Demographics
NPI:1528414984
Name:ELLISON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-1177
Mailing Address - Country:US
Mailing Address - Phone:304-645-3220
Mailing Address - Fax:304-647-1273
Practice Address - Street 1:400 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-1177
Practice Address - Country:US
Practice Address - Phone:304-645-3220
Practice Address - Fax:304-647-1273
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVED1234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine