Provider Demographics
NPI:1609978071
Name:MAMBERG, ELIAS (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIAS
Middle Name:
Last Name:MAMBERG
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 1:1301 N HARRISON ST
Mailing Address - Street 2:104
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806
Mailing Address - Country:US
Mailing Address - Phone:302-428-0337
Mailing Address - Fax:302-428-0645
Practice Address - Street 1:1301 N HARRISON ST
Practice Address - Street 2:104
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806
Practice Address - Country:US
Practice Address - Phone:302-428-0337
Practice Address - Fax:302-428-0645
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10000703207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000018501Medicaid
057416Medicare ID - Type Unspecified
B66339Medicare UPIN