Provider Demographics
NPI:1568642890
Name:ELLEN L. ELLSWORTH, OD INC
Entity Type:Organization
Organization Name:ELLEN L. ELLSWORTH, OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:LILLE
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-352-8031
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-03
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4277 T228152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0841316Medicaid
EL9324941Medicare PIN
0971390001Medicare NSC