Healthcare Provider Details

I. General information

NPI: 1336115922
Provider Name (Legal Business Name): JOHN HOLBERT ELLYSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 LOWE ST
JACKSON CA
95642-2544
US

IV. Provider business mailing address

340 LOWE ST
JACKSON CA
95642-2544
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-2474
  • Fax:
Mailing address:
  • Phone: 209-223-2474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG15379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: