Richard Ira Ellenbogen, DO

Primary specialty

Obstetrics & Gynecology PhysicianTaxonomy code 207V00000X

License

5101006200 Issued in MI

Practice address

4000 Highland Road
#120
Waterford, MI 48328

Phone

(248) 682-2109

Fax

(248) 682-4769

NPI assigned

Oct 12, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1160611200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1093804619",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4000 HIGHLAND ROAD",
            "address_2": "#120",
            "city": "WATERFORD",
            "state": "MI",
            "postal_code": "48328",
            "telephone_number": "248-682-2109",
            "fax_number": "248-682-4769"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4000 HIGHLAND ROAD",
            "address_2": "#120",
            "city": "WATERFORD",
            "state": "MI",
            "postal_code": "48328",
            "telephone_number": "248-682-2109",
            "fax_number": "248-682-4769"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "ELLENBOGEN",
        "first_name": "RICHARD",
        "middle_name": "IRA",
        "name_prefix": "Dr.",
        "credential": "DO",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-12",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "MI",
            "license": "5101006200",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Obstetrics & Gynecology Physician in Waterford, MI
• Providers in Waterford, MI by specialty
• Obstetrics & Gynecology Physician in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.