Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | 0786 | AZ |
N | 222Z00000X | Podiatrist | 0786 | AZ |
N | 2081S0010X | Sports Medicine | 0786 | AZ |
N | 213ES0000X | Sports Medicine | 0786 | AZ |
Y | 213ES0103X | Foot & Ankle Surgery | 0786 | AZ |
NPI | 1528355708 |
---|---|
Provider Name | David T Ellsworth |
First Address | Mesa, AZ 85209-1505 |
Second Address | Mesa, AZ 85206-4632 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2011 |
Last Update Date | 05/05/2016 |