Provider Demographics
NPI:1528131273
Name:ELLSWORTH, LINDA RAE (MD, PHD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:RAE
Last Name:ELLSWORTH
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Gender:F
Credentials:MD, PHD
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Other - Credentials:
Mailing Address - Street 1:4499 MEDICAL DR
Mailing Address - Street 2:SUITE 380
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3735
Mailing Address - Country:US
Mailing Address - Phone:210-614-3303
Mailing Address - Fax:210-615-1052
Practice Address - Street 1:4499 MEDICAL DR
Practice Address - Street 2:SUITE 380
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3735
Practice Address - Country:US
Practice Address - Phone:210-614-3303
Practice Address - Fax:210-615-1052
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TXG4114207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB22527Medicare UPIN