Provider Demographics
NPI:1043265689
Name:GARBO, ELLEN N (MD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:N
Last Name:GARBO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:YELENA
Other - Middle Name:N
Other - Last Name:GARBOUZOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:45 10TH ST W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-1062
Mailing Address - Country:US
Mailing Address - Phone:651-232-3640
Mailing Address - Fax:651-232-3632
Practice Address - Street 1:45 10TH ST W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-1062
Practice Address - Country:US
Practice Address - Phone:651-232-3640
Practice Address - Fax:651-232-3632
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN431512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN105102400Medicaid
MNH29861Medicare UPIN