Basic Information
| Provider Information | |||||||||
| NPI: | 1417948647 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLSWORTH | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10140 CENTURION PKWY N | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322560532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046974127 | ||||||||
| FaxNumber: | 9046975102 | ||||||||
| Practice Location | |||||||||
| Address1: | 13535 NEMOURS PKWY | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328277402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075674000 | ||||||||
| FaxNumber: | 4075675924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2005 | ||||||||
| LastUpdateDate: | 01/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 150422 | MA | N | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | ME129642 | FL | Y | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | MD11894 | RI | N | Allopathic & Osteopathic Physicians | Urology | 2088P0231X | 150422 | MA | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology |
ID Information
| ID | Type | State | Issuer | Description | 018993600 | 05 | FL | MEDICAID | 31017 | 01 | RI | BLUE SHIELD | OTHER | 3158667 | 05 | MA | MEDICAID | PE45993 | 05 | RI | MEDICAID |