Provider Demographics
NPI:1164524559
Name:MARDER, ELLEN J (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:J
Last Name:MARDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELLEN
Other - Middle Name:J
Other - Last Name:MACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:933 BRADBURY DR SE
Mailing Address - Street 2:SUITE 2222
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4374
Mailing Address - Country:US
Mailing Address - Phone:505-272-3120
Mailing Address - Fax:505-272-8060
Practice Address - Street 1:UNM CLINICAL NEUROSCIENCE CENTER 2211 LOMAS BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-3160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM 84-732084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX752919329OtherTAX ID
TX142097801Medicaid
TXD35802Medicare UPIN
TX752919329OtherTAX ID