Provider Demographics
NPI:1932119641
Name:ELLENBURG, LUKE L JR (MD)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:L
Last Name:ELLENBURG
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 1:801 E. CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37745-6219
Mailing Address - Country:US
Mailing Address - Phone:423-639-6848
Mailing Address - Fax:423-787-7210
Practice Address - Street 1:801 E. CHURCH ST
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37745-6219
Practice Address - Country:US
Practice Address - Phone:423-639-6848
Practice Address - Fax:423-787-7210
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD010682207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN31105711Medicaid
TND32051Medicare UPIN
TN31105711Medicaid