Provider Demographics
NPI:1548354475
Name:ELLENBURG, DONALD T (MD)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:T
Last Name:ELLENBURG
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 1:2121 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-1111
Mailing Address - Country:US
Mailing Address - Phone:865-525-2640
Mailing Address - Fax:865-525-9536
Practice Address - Street 1:2121 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-1111
Practice Address - Country:US
Practice Address - Phone:865-525-2640
Practice Address - Fax:865-525-9536
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31722208000000X
TN3958207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN15689OtherBCBS OF TN
TN3188882Medicaid
TN602002950OtherCARITEN
3188884Medicare ID - Type Unspecified
TN15689OtherBCBS OF TN