Provider Demographics
NPI:1780771675
Name:ELLSWORTH, STEVEN (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
Last Name:ELLSWORTH
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 1:5000 E UNIVERSITY BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-8149
Mailing Address - Country:US
Mailing Address - Phone:432-550-5525
Mailing Address - Fax:432-362-4594
Practice Address - Street 1:5000 E UNIVERSITY BLVD STE 6
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762-8149
Practice Address - Country:US
Practice Address - Phone:432-550-5525
Practice Address - Fax:432-362-4594
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5021174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist