Provider Demographics
NPI:1780786707
Name:ELLSWORTH, CHARLES PAUL (DO)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:PAUL
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:810-249-4037
Practice Address - Street 1:7057 N CLIO RD
Practice Address - Street 2:
Practice Address - City:MOUNT MORRIS
Practice Address - State:MI
Practice Address - Zip Code:48458-8261
Practice Address - Country:US
Practice Address - Phone:810-670-0200
Practice Address - Fax:810-670-0196
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101015196207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1051020OtherMCLAREN HEALTH PLAN
MN178241OtherGREAT LAKES HEALTH PLAN/UNITED HEALTHCARE
MN1780786707OtherMOLINA HEALTHCARE OF MICHIGAN
MI080G3610660OtherMICHIGAN BLUE CROSS BLUE SHIELD
MI1780786707Medicaid
MI381908328OtherHCAP
MN381908328-446OtherCARE SOURCE OF MICHIGAN
MI080G310660OtherBLUE CARE NETWORK OF MICHIGAN
MI0992950OtherHEALTH PLUS OF MICHIGAN
MI19870OtherHEALTH PLAN OF MICHIGAN
MI381908328OtherHCAP
MN178241OtherGREAT LAKES HEALTH PLAN/UNITED HEALTHCARE