Provider Demographics
NPI:1326332776
Name:ELLINGSON, CLINTON (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:
Last Name:ELLINGSON
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 1:2100 PROVIDENCE WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4951
Mailing Address - Country:US
Mailing Address - Phone:208-529-6600
Mailing Address - Fax:208-529-6600
Practice Address - Street 1:2100 PROVIDENCE WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4951
Practice Address - Country:US
Practice Address - Phone:208-529-6600
Practice Address - Fax:208-529-6602
Is Sole Proprietor?:No
Enumeration Date:2011-06-02
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49026207W00000X, 207WX0107X
IN01080410A207W00000X
IDM-15285207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1326332776Medicaid
OH0160321Medicaid
ID1326332776Medicaid
KY7100279250Medicaid
IN300021246Medicaid