Provider Demographics
NPI:1669427118
Name:ELLISON, JOHNNY R (DO)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:R
Last Name:ELLISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5000
Mailing Address - Fax:740-446-5625
Practice Address - Street 1:1051 4TH AVE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1612
Practice Address - Country:US
Practice Address - Phone:740-446-5244
Practice Address - Fax:740-446-5625
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-3700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
001714065OtherMOUNTAIN STATE BCBS
OH0555340OtherMOLINA MEDICAID
OH000000181981OtherUNISON MEDICAID
OH310917085105OtherCARESOURCE MEDICAID
WV0051040000Medicaid
000000007522OtherANTHEM BCBS
OH0555340Medicaid
080056559OtherRR MEDICARE
WV0549594Medicare PIN
OH0549595Medicare PIN
OH310917085105OtherCARESOURCE MEDICAID