Provider Demographics
NPI:1972671709
Name:ELLENBOGEN, ENRIQUE (MD)
Entity type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:
Last Name:ELLENBOGEN
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 1:700 S STANFIELD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2569
Mailing Address - Country:US
Mailing Address - Phone:937-335-7121
Mailing Address - Fax:937-335-7124
Practice Address - Street 1:700 S STANFIELD RD
Practice Address - Street 2:SUITE B
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2569
Practice Address - Country:US
Practice Address - Phone:937-335-7121
Practice Address - Fax:937-335-7124
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35100246207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHL0277598Medicaid
000000010310OtherANTHEM
OH311024334OtherTAX IDENTIFICATION NUMBER
D00246OtherHUMANA
OHL0277598Medicaid
OH311024334OtherTAX IDENTIFICATION NUMBER