Provider Demographics
NPI:1083877963
Name:ELLSWORTH, CHARLENE A (MD)
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:A
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 ELM ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4626
Mailing Address - Country:US
Mailing Address - Phone:877-771-7401
Mailing Address - Fax:401-784-4902
Practice Address - Street 1:375 WAMPANOAG TRL
Practice Address - Street 2:SUITE 301
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-2232
Practice Address - Country:US
Practice Address - Phone:401-649-4050
Practice Address - Fax:401-649-4051
Is Sole Proprietor?:No
Enumeration Date:2008-07-09
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14570207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine