Healthcare Provider Details

I. General information

NPI: 1760794093
Provider Name (Legal Business Name): JOSEPH TRENT ELLENBURG D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 HIGHLAND AVE
KNOXVILLE TN
37916-1111
US

IV. Provider business mailing address

5201 CATALINA RD
KNOXVILLE TN
37918-4510
US

V. Phone/Fax

Practice location:
  • Phone: 865-525-2640
  • Fax:
Mailing address:
  • Phone: 601-502-7410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT-2304
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2640
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2640
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2640
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: