Provider Demographics
NPI:1831279959
Name:OFFUTT, ELLEN JANN (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:JANN
Last Name:OFFUTT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6976 CONSTITUTION PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43235-2138
Mailing Address - Country:US
Mailing Address - Phone:614-840-9920
Mailing Address - Fax:
Practice Address - Street 1:6976 CONSTITUTION PL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-2138
Practice Address - Country:US
Practice Address - Phone:614-840-9920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH53143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHOF0578033Medicare ID - Type Unspecified
OHA82337Medicare UPIN