Provider Demographics
NPI:1124387618
Name:ELLSWORTH, MATTHEW MCKINLEY (DPM)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:MCKINLEY
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2379
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-2379
Mailing Address - Country:US
Mailing Address - Phone:606-408-6200
Mailing Address - Fax:606-408-6612
Practice Address - Street 1:613 23RD ST STE G30
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2881
Practice Address - Country:US
Practice Address - Phone:606-327-0036
Practice Address - Fax:606-326-1159
Is Sole Proprietor?:No
Enumeration Date:2012-05-03
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003921213E00000X
KY00426213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100351750Medicaid