Provider Demographics
NPI:1487915054
Name:ELLSWORTH, STEVEN K (DO)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:K
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1570 CANYON VIEW DR
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5572
Mailing Address - Country:US
Mailing Address - Phone:817-707-5450
Mailing Address - Fax:
Practice Address - Street 1:1380 E MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2123
Practice Address - Country:US
Practice Address - Phone:435-251-3037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12324607-1204207ZP0102X
VA390200000X
TN3456207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program