Provider Demographics
NPI:1336470343
Name:ELLSWORTH, WARREN ALDRICH IV (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:ALDRICH
Last Name:ELLSWORTH
Suffix:IV
Gender:M
Credentials:MD
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Mailing Address - Street 1:6560 FANNIN ST
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2761
Mailing Address - Country:US
Mailing Address - Phone:713-441-8082
Mailing Address - Fax:713-790-5020
Practice Address - Street 1:6560 FANNIN ST
Practice Address - Street 2:SUITE 2200
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2761
Practice Address - Country:US
Practice Address - Phone:713-441-8082
Practice Address - Fax:713-790-5020
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2014-07-07
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Provider Licenses
StateLicense IDTaxonomies
TXN4396208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1336470343OtherBLUE CROSS BLUE SHIELD
TX8EJ452OtherBLUE CROSS BLUE SHIELD
TXP00947675OtherMEDICARE RR
TXP00947675OtherMEDICARE RR
TXTXB111077Medicare PIN
TX350192ZGSGMedicare PIN