Healthcare Provider Details

I. General information

NPI: 1003221037
Provider Name (Legal Business Name): JOHN ELLIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2014
Last Update Date: 11/24/2025
Certification Date: 11/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 THIRD AVE
BRONX NY
10457
US

IV. Provider business mailing address

6751 EAGLE RIDGE BLVD
LAKELAND FL
33813-5636
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-9000
  • Fax:
Mailing address:
  • Phone: 727-417-6369
  • Fax: 954-377-3042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number160849
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberOS15644
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number22891
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: