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General NPI Number Information
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NPI Number | 1083619043
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Entity Type | Individual
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Provider Name | JOHN BRYAN ELLSWORTH M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/16/2005
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Last Update Date | 04/30/2025
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Provider Practice Location Address
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Address Line | 736 S 900 E STE 108
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City | ST GEORGE
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State | UT
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Zip | 84790
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Country | US
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Telephone | 435-628-3606
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Fax | 435-628-8404
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Provider Business Mailing Address
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Address Line | 736 S 900 E STE 108
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City | ST GEORGE
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State | UT
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Zip | 84790-7002
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Country | US
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Telephone | 435-628-3606
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Fax | 435-628-8404
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 188550-1205
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 15297
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License Number State | NV
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Taxonomy #3
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 77080
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License Number State | AZ
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