Provider Demographics
NPI:1831139112
Name:ELLENBY, JAY DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:JAY
Middle Name:DAVID
Last Name:ELLENBY
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 1:2954 B AVENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3102
Mailing Address - Country:US
Mailing Address - Phone:305-933-6033
Mailing Address - Fax:305-933-5978
Practice Address - Street 1:2954 B AVENTURA BLVD
Practice Address - Street 2:
Practice Address - City:AVENTURA
Practice Address - State:FL
Practice Address - Zip Code:33180-3102
Practice Address - Country:US
Practice Address - Phone:305-933-6033
Practice Address - Fax:305-933-5978
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME12885208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
33073AMedicare ID - Type Unspecified
FLW11325Medicare UPIN