Provider Demographics
NPI:1306826896
Name:ELLSWORTH, ERIK G (MD)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:G
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 1:3200 E CAMELBACK RD STE 250
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2327
Mailing Address - Country:US
Mailing Address - Phone:602-933-1815
Mailing Address - Fax:
Practice Address - Street 1:1501 N GILBERT RD STE 203
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-2394
Practice Address - Country:US
Practice Address - Phone:602-933-3366
Practice Address - Fax:602-933-4264
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ415692080P0202X, 2080P0202X
TXTRAINEE2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ404994Medicaid
MN370002899Medicare ID - Type Unspecified
I15053Medicare UPIN