MEDICARE: DR. JOHN S ELLIS 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	OA05056	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	630717YCT	OTHER	NJ	MEDICARE PTAN

General Provider Information

NPI Number	:	1871569244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN S ELLIS OD

Provider Business Mailing Address
First Line	:	691 ROUTE 9 S
Second Line	:	MILLERS MALL - UNIT 4
City	:	LITTLE EGG HARBOR TWP
State	:	NJ
Zip	:	08087-4020
Country	:	US
Telephone Number	:	609-294-8144
Fax Number	:	609-812-5190

Provider Business Practice Location Address
First Line	:	691 ROUTE 9 S
Second Line	:	MILLERS MALL - UNIT 4
City	:	LITTLE EGG HARBOR TWP
State	:	NJ
Zip	:	08087-4020
Country	:	US
Telephone Number	:	609-294-8144
Fax Number	:	609-812-5190

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

Provider Enumeration Date	:	02/27/2006
Last Update Date	:	02/10/2012

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