Provider Demographics
NPI:1245556141
Name:ELLSWORTH, RONALD K (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:K
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:ID
Mailing Address - Zip Code:83611-1330
Mailing Address - Country:US
Mailing Address - Phone:208-382-4242
Mailing Address - Fax:208-382-5081
Practice Address - Street 1:402 LAKE CASCADE PKWY
Practice Address - Street 2:
Practice Address - City:CASCADE
Practice Address - State:ID
Practice Address - Zip Code:83611-7702
Practice Address - Country:US
Practice Address - Phone:208-382-4242
Practice Address - Fax:208-382-5081
Is Sole Proprietor?:No
Enumeration Date:2010-04-16
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-11978207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine