Provider Demographics
NPI:1174865455
Name:ELLEDGE, BRIAN EUGENE (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:EUGENE
Last Name:ELLEDGE
Suffix:
Gender:M
Credentials:DO
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 742353
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2353
Mailing Address - Country:US
Mailing Address - Phone:310-482-8403
Mailing Address - Fax:
Practice Address - Street 1:1000 E 100 N
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1600
Practice Address - Country:US
Practice Address - Phone:801-465-7041
Practice Address - Fax:801-465-7409
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A149042084P0800X
UT9848744-12042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry