Provider Demographics
NPI:1962585745
Name:ELLERTON, JOHN ALLAN (MD, CM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ALLAN
Last Name:ELLERTON
Suffix:
Gender:M
Credentials:MD, CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:702-724-8777
Mailing Address - Fax:702-352-2790
Practice Address - Street 1:6190 S FORT APACHE RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-6702
Practice Address - Country:US
Practice Address - Phone:702-724-8777
Practice Address - Fax:702-352-2790
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39440207RH0003X
NV3861207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV20-02623Medicaid
NV3861OtherLICENSE
CAG39440OtherLICENSE
NV01673965OtherAMERIGROUP
NV0098707OtherCIGNA
NVP01062140OtherRAILROAD MEDICARE
NV4297063OtherAETNA
NVGE779ZMedicare PIN
NVV50227Medicare PIN
NV20-02623Medicaid
NV0098707OtherCIGNA