Provider Demographics
NPI:1043319098
Name:ELLWANGER, FREDERICK R III (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:R
Last Name:ELLWANGER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:749 WILD OAK LN NW
Mailing Address - Street 2:
Mailing Address - City:CALABASH
Mailing Address - State:NC
Mailing Address - Zip Code:28467-1939
Mailing Address - Country:US
Mailing Address - Phone:910-575-7678
Mailing Address - Fax:910-575-7678
Practice Address - Street 1:749 WILD OAK LN NW
Practice Address - Street 2:
Practice Address - City:CALABASH
Practice Address - State:NC
Practice Address - Zip Code:28467-1939
Practice Address - Country:US
Practice Address - Phone:910-575-7678
Practice Address - Fax:910-575-7678
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC189442085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D60970Medicare UPIN