Provider Demographics
NPI:1750657649
Name:INGULSRUD, ERIC B (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:B
Last Name:INGULSRUD
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 1:1613 HARRISON PKWY
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-2896
Mailing Address - Country:US
Mailing Address - Phone:954-838-2371
Mailing Address - Fax:954-616-3866
Practice Address - Street 1:1431 SW 1ST AVENUE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-401-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-26
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME125002207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program