Provider Demographics
NPI:1588635627
Name:ELLSWORTH, RANDAL N (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:N
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 1:510 W 650 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6136
Mailing Address - Country:US
Mailing Address - Phone:801-225-1717
Mailing Address - Fax:
Practice Address - Street 1:1735 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1010
Practice Address - Country:US
Practice Address - Phone:801-374-1818
Practice Address - Fax:801-379-2959
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT942742051205174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist