Provider Demographics
NPI:1689755605
Name:ELLENBERGER, HOWARD H (OD, PHD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:H
Last Name:ELLENBERGER
Suffix:
Gender:M
Credentials:OD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 MOUNT WITTENBURG CT
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1057
Mailing Address - Country:US
Mailing Address - Phone:415-492-8698
Mailing Address - Fax:
Practice Address - Street 1:901 A ST
Practice Address - Street 2:SUITE C
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3043
Practice Address - Country:US
Practice Address - Phone:415-453-8906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13171 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist