Provider Demographics
NPI:1356970321
Name:ELLENBERGER, ALEX BLAIR (MD)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:BLAIR
Last Name:ELLENBERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 W COPELAND DR FL 1
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2002
Mailing Address - Country:US
Mailing Address - Phone:321-843-8900
Mailing Address - Fax:321-843-8916
Practice Address - Street 1:89 W COPELAND DR FL 1
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2002
Practice Address - Country:US
Practice Address - Phone:321-843-8900
Practice Address - Fax:321-843-8916
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2025-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME174405208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program