Provider Demographics
NPI:1871533547
Name:ELLEN, JONATHAN MARK (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MARK
Last Name:ELLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7676 NEW HAMPSHIRE AVE STE 220A
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-7514
Mailing Address - Country:US
Mailing Address - Phone:240-297-6758
Mailing Address - Fax:
Practice Address - Street 1:7676 NEW HAMPSHIRE AVE STE 220A
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-7514
Practice Address - Country:US
Practice Address - Phone:240-297-6758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD54679208000000X
FLME110221208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD472901300Medicaid
MDG02760Medicare UPIN
MD472901300Medicaid