Provider Demographics
NPI:1487817904
Name:KELLENBERGER, EDWARD F (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:F
Last Name:KELLENBERGER
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:PO BOX 417
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995-0417
Mailing Address - Country:US
Mailing Address - Phone:772-223-2832
Mailing Address - Fax:772-419-3811
Practice Address - Street 1:10050 SW INNOVATION WAY STE 102
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2117
Practice Address - Country:US
Practice Address - Phone:772-344-3811
Practice Address - Fax:772-335-2422
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1206302084N0400X, 2084N0400X
NC2016-006362084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012834800Medicaid
FLP01366910OtherRAILROAD MEDICARE
FLP01366910OtherRAILROAD MEDICARE