Provider Demographics
NPI:1952344988
Name:PRYOR, ELLSWORTH PAXTON (MD)
Entity Type:Individual
Prefix:
First Name:ELLSWORTH
Middle Name:PAXTON
Last Name:PRYOR
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 1:23928 LYONS AVE
Mailing Address - Street 2:208
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321
Mailing Address - Country:US
Mailing Address - Phone:661-255-8544
Mailing Address - Fax:
Practice Address - Street 1:23928 LYONS AVE
Practice Address - Street 2:208
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2409
Practice Address - Country:US
Practice Address - Phone:661-255-8544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29880207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G298800Medicaid
CAA44206Medicare UPIN
CA00G298800Medicaid