Provider Demographics
NPI:1811974629
Name:ELLIS, JOHN J (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:ELLIS
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-0549
Mailing Address - Country:US
Mailing Address - Phone:719-530-2000
Mailing Address - Fax:719-530-2055
Practice Address - Street 1:550 W HWY 50
Practice Address - Street 2:
Practice Address - City:SALIDA
Practice Address - State:CO
Practice Address - Zip Code:81201-2238
Practice Address - Country:US
Practice Address - Phone:719-530-2000
Practice Address - Fax:719-530-2055
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO24459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62584251Medicaid
COCO302001Medicare PIN