Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 36002463E | OH |
Y | 222Z00000X | Podiatrist | 36002463E | OH |
NPI | 1043384795 |
---|---|
Provider Name | John P Ellis |
First Address | Fairview Park, OH 44126-3333 |
Second Address | Fairview Park, OH 44126-3333 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/11/2006 |
Last Update Date | 23/01/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0691845 | (05) | OH |
T80656 | (02) |