Provider Demographics
NPI:1336115922
Name:ELLYSON, JOHN HOLBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HOLBERT
Last Name:ELLYSON
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 1:340 LOWE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2544
Mailing Address - Country:US
Mailing Address - Phone:209-223-2474
Mailing Address - Fax:
Practice Address - Street 1:340 LOWE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2544
Practice Address - Country:US
Practice Address - Phone:209-223-2474
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15379208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39514Medicare UPIN