Individual
DR. ENRIQUE ELLENBOGEN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
700 S STANFIELD RD, SUITE B, TROY, OH 45373-2569
(937) 335-7121
(937) 335-7124
Mailing address
700 S STANFIELD RD, SUITE B, TROY, OH 45373-2569
(937) 335-7121
(937) 335-7124
Taxonomy
Speciality
Code
Description
License number
State
207W00000X
Ophthalmology Physician
Primary
35100246
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000010310
ANTHEM
—
01
—
311024334
TAX IDENTIFICATION NUMBER
OH
01
—
D00246
HUMANA
—
05
—
L0277598
—
OH
Enumeration date
12/01/2006
Last updated
01/18/2012
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