Provider Demographics
NPI:1093730277
Name:ELLSWORTH, RICHARD KIPP (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:KIPP
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:460 GREENFIELD AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-3500
Mailing Address - Country:US
Mailing Address - Phone:559-584-0141
Mailing Address - Fax:559-584-5711
Practice Address - Street 1:460 GREENFIELD AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3500
Practice Address - Country:US
Practice Address - Phone:559-584-0141
Practice Address - Fax:559-584-5711
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2008-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A46140204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A46140Medicaid
CAA46140OtherSTATE LICENSE
CA020A46140Medicaid
CA020A46140Medicare PIN