Provider Demographics
NPI:1093804619
Name:ELLENBOGEN, RICHARD IRA (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:IRA
Last Name:ELLENBOGEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 HIGHLAND ROAD
Mailing Address - Street 2:#120
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48328
Mailing Address - Country:US
Mailing Address - Phone:248-682-2109
Mailing Address - Fax:248-682-4769
Practice Address - Street 1:4000 HIGHLAND ROAD
Practice Address - Street 2:#120
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328
Practice Address - Country:US
Practice Address - Phone:248-682-2109
Practice Address - Fax:248-682-4769
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006200207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E26574Medicare UPIN
5633280161Medicare ID - Type Unspecified