Provider Demographics
NPI:1760630669
Name:ELLISON, JON GABRIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:GABRIEL
Last Name:ELLISON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7777 ALVARADO RD STE 108
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-8245
Mailing Address - Country:US
Mailing Address - Phone:619-460-2774
Mailing Address - Fax:619-460-2774
Practice Address - Street 1:7777 ALVARADO RD STE 108
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-8245
Practice Address - Country:US
Practice Address - Phone:619-460-2774
Practice Address - Fax:619-460-2774
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL1250494762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology