Provider Demographics
NPI:1053547141
Name:RANDAL N ELLSWORTH M.D. PC
Entity type:Organization
Organization Name:RANDAL N ELLSWORTH M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:NYLAN
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:435-656-2020
Mailing Address - Street 1:510 W 650 S
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6136
Mailing Address - Country:US
Mailing Address - Phone:435-656-2020
Mailing Address - Fax:435-673-4131
Practice Address - Street 1:1791 E 280 N
Practice Address - Street 2:
Practice Address - City:SAINT GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2400
Practice Address - Country:US
Practice Address - Phone:435-656-2020
Practice Address - Fax:435-673-4131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT274205-1205207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty