Provider Demographics
NPI:1306343132
Name:ELLSWORTH, VICTORIA ERNESTINA (MD)
Entity type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:ERNESTINA
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:RAZON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 737
Mailing Address - Street 2:
Mailing Address - City:SAN JOAQUIN
Mailing Address - State:CA
Mailing Address - Zip Code:93660-0737
Mailing Address - Country:US
Mailing Address - Phone:559-203-6640
Mailing Address - Fax:
Practice Address - Street 1:4711 W ASHLAN AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722
Practice Address - Country:US
Practice Address - Phone:559-203-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program