Provider Demographics
NPI:1083619043
Name:ELLSWORTH, JOHN BRYAN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRYAN
Last Name:ELLSWORTH
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:736 S 900 E STE 108
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-7002
Mailing Address - Country:US
Mailing Address - Phone:435-628-3606
Mailing Address - Fax:435-628-8404
Practice Address - Street 1:736 S 900 E STE 108
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790
Practice Address - Country:US
Practice Address - Phone:435-628-3606
Practice Address - Fax:435-628-8404
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT188550-1205174400000X
NV15297208800000X
AZ77080208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT68471OtherPEHP
UT751575OtherDMBA
UT870562879ELLOtherEMIA
UTQM0000076522OtherALTIUS
UT6411882OtherCIGNA
NVV108245OtherMEDICARE ID FOR NEVADA PRACTICE LOCATION
UT005575530OtherHUMANA
UT340020123OtherRR MEDICARE
UT107011798101OtherIHC
UT18855012000001OtherBC BS
UT18855012000001OtherBC BS
UT005575530Medicare ID - Type Unspecified