Provider Demographics
NPI:1952309312
Name:ELLIS, JOHN III (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ELLIS
Suffix:III
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:511 MARKET BLVD STE 105
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2360
Practice Address - Country:US
Practice Address - Phone:901-457-2880
Practice Address - Fax:901-457-2881
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3007859Medicaid
TN3007859Medicaid