Provider Demographics
NPI:1942367214
Name:ELLINGTON, MARTY JR (MD MPH)
Entity Type:Individual
Prefix:DR
First Name:MARTY
Middle Name:
Last Name:ELLINGTON
Suffix:JR
Gender:M
Credentials:MD MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 W 118TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1809
Mailing Address - Country:US
Mailing Address - Phone:212-932-1011
Mailing Address - Fax:212-932-3133
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1850
Practice Address - Country:US
Practice Address - Phone:212-434-3351
Practice Address - Fax:212-434-3374
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2143632080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01977733Medicaid
F9772Medicare UPIN