Healthcare Provider Details

I. General information

NPI: 1528131273
Provider Name (Legal Business Name): LINDA RAE ELLSWORTH M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4499 MEDICAL DR SUITE 380
SAN ANTONIO TX
78229-3735
US

IV. Provider business mailing address

4499 MEDICAL DR SUITE 380
SAN ANTONIO TX
78229-3735
US

V. Phone/Fax

Practice location:
  • Phone: 210-614-3303
  • Fax: 210-615-1052
Mailing address:
  • Phone: 210-614-3303
  • Fax: 210-615-1052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberG4114
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: