Provider Demographics
NPI:1417914540
Name:ELLENBOGEN, CHARLOTTE L (DO)
Entity Type:Individual
Prefix:DR
First Name:CHARLOTTE
Middle Name:L
Last Name:ELLENBOGEN
Suffix:
Gender:F
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:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80034-1449
Mailing Address - Country:US
Mailing Address - Phone:303-425-9245
Mailing Address - Fax:303-425-1378
Practice Address - Street 1:3885 UPHAM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4880
Practice Address - Country:US
Practice Address - Phone:303-425-9245
Practice Address - Fax:303-425-1378
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO53322207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03611509Medicaid
ILK27712Medicare PIN
ILK27710Medicare PIN
ILI52346Medicare UPIN
IL03611509Medicaid