Provider Demographics
NPI:1982600193
Name:ELLIS, JON MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:MICHAEL
Last Name:ELLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 848491
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-8491
Mailing Address - Country:US
Mailing Address - Phone:254-202-9330
Mailing Address - Fax:254-202-9349
Practice Address - Street 1:140 HILLCREST MEDICAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8897
Practice Address - Country:US
Practice Address - Phone:254-741-1400
Practice Address - Fax:254-741-1428
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2020-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9580207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX046446302Medicaid
TXH22199Medicare UPIN
TX046446302Medicaid
TX200046376Medicare PIN