Provider Demographics
NPI:1841231842
Name:ELLSWORTH, JOHN E (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:E
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:E
Other - Last Name:ELLSWORTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2181 OLYMPIC ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2767
Mailing Address - Country:US
Mailing Address - Phone:937-390-9080
Mailing Address - Fax:937-390-9075
Practice Address - Street 1:2181 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2767
Practice Address - Country:US
Practice Address - Phone:937-390-9080
Practice Address - Fax:937-390-9075
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3684111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U53843Medicare UPIN