Provider Demographics
NPI:1104130574
Name:ELLSWORTH, RYAN SCOTT (DPM)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:SCOTT
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9980 S 300 W STE 300
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-3654
Mailing Address - Country:US
Mailing Address - Phone:801-273-0001
Mailing Address - Fax:801-253-6888
Practice Address - Street 1:505 FAIRBURN RD SW STE 100
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2012
Practice Address - Country:US
Practice Address - Phone:404-618-6077
Practice Address - Fax:801-253-6888
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV2109213E00000X
CAE5797213E00000X
FLPO4406213E00000X
GAPOD001473213E00000X
UT8400193-0501213EP1101X, 213ER0200X, 213ES0000X, 213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1003111Medicaid
UT8400193-0501OtherUT DPM LICENSE
UT7672880001OtherDME
CAE5797OtherCA DPM LICENSE
GAPOD001473OtherGA DPM LICENSE
FLPO4406OtherFL DPM LICENSE
NV2109OtherNV DPM LICENSE