Provider Demographics
NPI:1700855012
Name:ELLENBOLT, DARREN R (MD)
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:R
Last Name:ELLENBOLT
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N17 W24100 RIVERWOOD DR.
Mailing Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES, INC.
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1177
Mailing Address - Country:US
Mailing Address - Phone:262-928-4100
Mailing Address - Fax:262-928-5835
Practice Address - Street 1:240 MAPLE AVE.
Practice Address - Street 2:PROHEALTH CARE MEDICAL ASSOCIATES, INC.
Practice Address - City:MUKWONAGO
Practice Address - State:WI
Practice Address - Zip Code:53149-8475
Practice Address - Country:US
Practice Address - Phone:262-928-1900
Practice Address - Fax:262-363-1949
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI47860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34847400Medicaid
WI011668605Medicare PIN
WII55617Medicare UPIN
WI683750606Medicare PIN