Provider Demographics
NPI:1669457024
Name:ELLSWORTH, KEVIN MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:MARK
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 E 1400 N
Mailing Address - Street 2:SUITE B
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-7573
Mailing Address - Country:US
Mailing Address - Phone:435-752-5585
Mailing Address - Fax:435-787-2871
Practice Address - Street 1:395 E 1400 N
Practice Address - Street 2:SUITE B
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-7573
Practice Address - Country:US
Practice Address - Phone:435-752-5585
Practice Address - Fax:435-787-2871
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT112376-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000009827Medicare PIN
UTT78174Medicare UPIN