Provider Demographics
NPI:1487787362
Name:LEBOW, ELLEN WENDY (DO)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:WENDY
Last Name:LEBOW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21110 BISCAYNE BLVD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-1227
Mailing Address - Country:US
Mailing Address - Phone:305-933-3030
Mailing Address - Fax:305-933-1436
Practice Address - Street 1:21110 BISCAYNE BLVD
Practice Address - Street 2:SUITE 312
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-1227
Practice Address - Country:US
Practice Address - Phone:305-933-3030
Practice Address - Fax:305-933-1436
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0S5155174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL80332OtherBLUE CROSS BLUE SHIELD
FL80332ZMedicare ID - Type Unspecified
FLE73751Medicare UPIN