Healthcare Provider Details

I. General information

NPI: 1427311455
Provider Name (Legal Business Name): JOHN ELLIE JR. D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 03/17/2022
Certification Date: 03/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 PORTLAND AVE PODIATRY SUITE
ROCHESTER NY
14621-3065
US

IV. Provider business mailing address

1500 PORTLAND AVE PODIATRY/MED OFFICE
ROCHESTER NY
14621
US

V. Phone/Fax

Practice location:
  • Phone: 585-642-6100
  • Fax: 585-642-6111
Mailing address:
  • Phone: 585-642-6100
  • Fax: 585-642-6111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number006649
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: