Provider Demographics
NPI:1538104427
Name:ELLENBERG, GILAD (MD)
Entity type:Individual
Prefix:DR
First Name:GILAD
Middle Name:
Last Name:ELLENBERG
Suffix:
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 1:68 PICCADILLY RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023-1547
Mailing Address - Country:US
Mailing Address - Phone:516-773-3399
Mailing Address - Fax:
Practice Address - Street 1:8601 HOMELAWN ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2635
Practice Address - Country:US
Practice Address - Phone:718-739-0355
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY127287-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00467827Medicaid
NY20467Medicare ID - Type Unspecified
NY00467827Medicaid