Individual
DARREN R. ELLENBOLT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
240 MAPLE AVE., PROHEALTH CARE MEDICAL ASSOCIATES, INC., MUKWONAGO, WI 53149-8475
(262) 928-1900
(262) 363-1949
Mailing address
N17 W24100 RIVERWOOD DR., PROHEALTH CARE MEDICAL ASSOCIATES, INC., WAUKESHA, WI 53188-1177
(262) 928-4100
(262) 928-5835
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
47860
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
34847400
—
WI
Enumeration date
03/17/2006
Last updated
11/02/2011
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