Provider Demographics
NPI:1417948647
Name:ELLSWORTH, PAMELA I (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:I
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4127
Mailing Address - Fax:904-697-5102
Practice Address - Street 1:13535 NEMOURS PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32827-7402
Practice Address - Country:US
Practice Address - Phone:407-567-4000
Practice Address - Fax:407-567-5924
Is Sole Proprietor?:No
Enumeration Date:2005-11-05
Last Update Date:2018-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA150422208800000X, 2088P0231X
FLME1296422088P0231X
RIMD11894208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018993600Medicaid
RI31017OtherBLUE SHIELD
MA3158667Medicaid
RIPE45993Medicaid
MA3158667Medicaid
MAA2200001Medicare PIN
RI31017OtherBLUE SHIELD