MEDICARE: DR. JOHN L ELLIS II OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5395T6	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	4722920001	OTHER		MEDICARE PALMETTO
8	P00113768	OTHER		MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	143852	OTHER		COLE VISION
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	5395	OTHER	TX	EYEMED VISION
6	807829	OTHER	TX	BLUE CROSS BLUE SHIELD
7	914210	OTHER		BLOCK VISION

General Provider Information

NPI Number	:	1417947417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN L ELLIS II OD

Provider Business Mailing Address
First Line	:	3800 N MESA ST
Second Line	:	STE B1
City	:	EL PASO
State	:	TX
Zip	:	79902-1535
Country	:	US
Telephone Number	:	915-533-1811
Fax Number	:	915-533-3641

Provider Business Practice Location Address
First Line	:	3800 N MESA
Second Line	:	STE C8
City	:	EL PASO
State	:	TX
Zip	:	79902
Country	:	US
Telephone Number	:	915-533-1811
Fax Number	:	915-533-3641

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2005
Last Update Date	:	10/20/2016

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