Provider Demographics
NPI:1073594339
Name:EBENSBERGER, JOHN R (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:EBENSBERGER
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 1:11779 JAY AVE
Mailing Address - Street 2:
Mailing Address - City:GREENE
Mailing Address - State:IA
Mailing Address - Zip Code:50636-9023
Mailing Address - Country:US
Mailing Address - Phone:641-823-4679
Mailing Address - Fax:
Practice Address - Street 1:11779 JAY AVE
Practice Address - Street 2:
Practice Address - City:GREENE
Practice Address - State:IA
Practice Address - Zip Code:50636-9023
Practice Address - Country:US
Practice Address - Phone:641-823-4679
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA21584207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAA01445Medicare UPIN