Healthcare Provider Details

I. General information

NPI: 1528355708
Provider Name (Legal Business Name): DAVID T ELLSWORTH D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4121 E VALLEY AUTO DR STE 110
MESA AZ
85206-4632
US

IV. Provider business mailing address

9233 E NEVILLE AVE UNIT 1033
MESA AZ
85209-1505
US

V. Phone/Fax

Practice location:
  • Phone: 480-892-1540
  • Fax: 480-892-2243
Mailing address:
  • Phone: 480-310-6015
  • Fax: 480-892-2243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0786
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number0786
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0786
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: