Healthcare Provider Details

I. General information

NPI: 1174865455
Provider Name (Legal Business Name): BRIAN EUGENE ELLEDGE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 100 N
PAYSON UT
84651-1600
US

IV. Provider business mailing address

PO BOX 742353
ATLANTA GA
30374-2353
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-7041
  • Fax: 801-465-7409
Mailing address:
  • Phone: 310-482-8403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A14904
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9848744-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: