Provider Demographics
NPI:1023255536
Name:ELLENBERGER, CARL JR (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:ELLENBERGER
Suffix:JR
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:PO BOX 70
Mailing Address - Street 2:96 BIRCH AV
Mailing Address - City:MOUNT GRETNA
Mailing Address - State:PA
Mailing Address - Zip Code:17064-0070
Mailing Address - Country:US
Mailing Address - Phone:717-964-3885
Mailing Address - Fax:717-964-3885
Practice Address - Street 1:96 BIRCH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT GRETNA
Practice Address - State:PA
Practice Address - Zip Code:17064-0070
Practice Address - Country:US
Practice Address - Phone:717-964-3885
Practice Address - Fax:717-964-3885
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 187872084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology