Provider Demographics
NPI:1134394836
Name:ELLENSTEIN, AVIVA (MD, PHD)
Entity type:Individual
Prefix:
First Name:AVIVA
Middle Name:
Last Name:ELLENSTEIN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 TOWER OAKS BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4238
Mailing Address - Country:US
Mailing Address - Phone:301-718-9611
Mailing Address - Fax:
Practice Address - Street 1:3202 TOWER OAKS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4238
Practice Address - Country:US
Practice Address - Phone:301-718-9611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0407742084N0400X
MDD675842084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology