Provider Demographics
NPI:1083619043
Name:ELLSWORTH, J. BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:BRYAN
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 1:736 S 900 E STE 108
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7002
Mailing Address - Country:US
Mailing Address - Phone:435-628-3606
Mailing Address - Fax:435-628-8404
Practice Address - Street 1:736 S 900 E STE 108
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-628-3606
Practice Address - Fax:435-628-8404
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV15297208800000X
UT188550-1205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005575530OtherHUMANA
UT6411882OtherCIGNA
UT751575OtherDMBA
UT870562879ELLOtherEMIA
NVV108245OtherMEDICARE ID FOR NEVADA PRACTICE LOCATION
UT68471OtherPEHP
UT18855012000001OtherBC BS
UT340020123OtherRR MEDICARE
UT107011798101OtherIHC
UTQM0000076522OtherALTIUS
UT18855012000001OtherBC BS
UT005575530Medicare ID - Type Unspecified