Provider Demographics
NPI:1962465971
Name:ELLIS, JOHN E (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:ELLIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:619 E CRAWFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-2102
Mailing Address - Country:US
Mailing Address - Phone:724-628-1370
Mailing Address - Fax:724-628-7314
Practice Address - Street 1:619 E CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:CONNELLSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15425-2102
Practice Address - Country:US
Practice Address - Phone:724-628-1370
Practice Address - Fax:724-628-7314
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001091152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009205OtherDORAL
PA397414OtherADVANTRA
PA397414OtherHEALTH ASSURANCE
PAP00230647OtherUNITED HEALTHCARE
PA1451095OtherUMWA
PA0014138740003Medicaid
PA137989OtherEYEMED
EL715656OtherPA BLUE SHIELD
PA123681OtherAETNA
PA03770OtherGATEWAY
PA118173OtherUNISON
PA207741OtherUPMC
PA715656Medicare PIN