Provider Demographics
NPI:1437297264
Name:ELLSWORTH, ELLEN LILLE (OD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:LILLE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9930 JOHNNYCAKE RIDGE RD
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6752
Mailing Address - Country:US
Mailing Address - Phone:440-352-8031
Mailing Address - Fax:440-352-7671
Practice Address - Street 1:9930 JOHNNYCAKE RIDGE RD
Practice Address - Street 2:SUITE 4B
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6752
Practice Address - Country:US
Practice Address - Phone:440-352-8031
Practice Address - Fax:440-352-7671
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4277 T228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0841316Medicaid
OH0841316Medicaid
OHEL0705253Medicare ID - Type Unspecified
0971390001Medicare NSC