Healthcare Provider Details

I. General information

NPI: 1093845943
Provider Name (Legal Business Name): JOHN MASOU ELLISON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23625 WR HOLMAN HIGHWAY
MONTEREY CA
93940
US

IV. Provider business mailing address

PO BOX HH BUSINESS DEVELOPMENT DEPARTMENT
MONTEREY CA
93940
US

V. Phone/Fax

Practice location:
  • Phone: 831-624-5311
  • Fax: 831-625-4948
Mailing address:
  • Phone: 831-622-2716
  • Fax: 831-625-4764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG79299
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: