Provider Demographics
NPI:1578580593
Name:ELLBOGEN, MARTIN H JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:H
Last Name:ELLBOGEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2698 ARDON LN
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3902
Mailing Address - Country:US
Mailing Address - Phone:307-237-7806
Mailing Address - Fax:
Practice Address - Street 1:1450 E A ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2239
Practice Address - Country:US
Practice Address - Phone:307-234-8700
Practice Address - Fax:307-234-8750
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WY6404A208M00000X, 207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G35104Medicare UPIN