Healthcare Provider Details

I. General information

NPI: 1487787362
Provider Name (Legal Business Name): ELLEN WENDY LEBOW D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21110 BISCAYNE BLVD SUITE 312
AVENTURA FL
33180-1227
US

IV. Provider business mailing address

21110 BISCAYNE BLVD SUITE 312
AVENTURA FL
33180-1227
US

V. Phone/Fax

Practice location:
  • Phone: 305-933-3030
  • Fax: 305-933-1436
Mailing address:
  • Phone: 305-933-3030
  • Fax: 305-933-1436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number0S5155
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: