Provider Demographics
NPI:1427311455
Name:ELLIE, JOHN JR (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ELLIE
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 PORTLAND AVE
Mailing Address - Street 2:PODIATRY/MED OFFICE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-642-6100
Mailing Address - Fax:585-642-6111
Practice Address - Street 1:1500 PORTLAND AVE
Practice Address - Street 2:PODIATRY SUITE
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3065
Practice Address - Country:US
Practice Address - Phone:585-642-6100
Practice Address - Fax:585-642-6111
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006649213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05448155Medicaid
NY04203352Medicaid