Provider Demographics
NPI:1578580593
Name:ELLBOGEN, MARTIN H JR (MD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:H
Last Name:ELLBOGEN
Suffix:JR
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 1:2698 ARDON LN
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3902
Mailing Address - Country:US
Mailing Address - Phone:307-237-7806
Mailing Address - Fax:
Practice Address - Street 1:834 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-2443
Practice Address - Country:US
Practice Address - Phone:360-379-2260
Practice Address - Fax:360-379-8352
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6404A207R00000X, 207RI0200X, 208M00000X
WAMD00043681207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
G35104Medicare UPIN