Provider Demographics
NPI:1891146239
Name:ELLENBERG, LEAH RACHEL (OD)
Entity Type:Individual
Prefix:DR
First Name:LEAH
Middle Name:RACHEL
Last Name:ELLENBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 GLENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1837
Mailing Address - Country:US
Mailing Address - Phone:516-509-8680
Mailing Address - Fax:
Practice Address - Street 1:33 W 42ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-8005
Practice Address - Country:US
Practice Address - Phone:516-509-8680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008461152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist