Provider Demographics
NPI:1154809002
Name:KELLY, STEVEN ELLSWORTH (MD)
Entity type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:ELLSWORTH
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:680 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2241
Mailing Address - Country:US
Mailing Address - Phone:801-768-8800
Mailing Address - Fax:801-820-8200
Practice Address - Street 1:62 E THRIVE DR STE 220
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:UT
Practice Address - Zip Code:84045-5560
Practice Address - Country:US
Practice Address - Phone:801-768-8800
Practice Address - Fax:801-820-8200
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12750920-1205207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology