Provider Demographics
NPI:1841588555
Name:ELLENBERGER, DOUGLAS WILLIAM (OD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:WILLIAM
Last Name:ELLENBERGER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 INTERSTATE PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-5625
Mailing Address - Country:US
Mailing Address - Phone:706-651-2020
Mailing Address - Fax:706-651-2032
Practice Address - Street 1:1330 INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5625
Practice Address - Country:US
Practice Address - Phone:706-651-2020
Practice Address - Fax:706-651-2032
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002659152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA013147572AMedicaid
GA202I410520Medicare PIN