Provider Demographics
NPI:1477547008
Name:ELLSWORTH, EDWARD L (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:L
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:PO BOX 31001
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-2078
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:815 POLLARD RD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-1438
Practice Address - Country:US
Practice Address - Phone:408-866-4060
Practice Address - Fax:419-866-5453
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA21796207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A217960Medicaid
CA00A217961Medicare ID - Type Unspecified
CA00A217960Medicaid