Healthcare Provider Details

I. General information

NPI: 1326629049
Provider Name (Legal Business Name): ALYSSA L ELLERBROCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 08/07/2024
Certification Date: 08/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8000 RESEARCH FOREST DR STE 360
SPRING TX
77382-1559
US

IV. Provider business mailing address

8000 RESEARCH FOREST DR STE 360
SPRING TX
77382-1559
US

V. Phone/Fax

Practice location:
  • Phone: 281-292-1191
  • Fax:
Mailing address:
  • Phone: 281-292-1191
  • Fax: 936-539-3635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10074828
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU2478
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: