Provider Demographics
NPI:1003907916
Name:ELLNER, LAURENCE STEVEN (DPM)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:STEVEN
Last Name:ELLNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2287 MOWRY AVE
Mailing Address - Street 2:STE C
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1622
Mailing Address - Country:US
Mailing Address - Phone:510-713-6559
Mailing Address - Fax:510-713-6537
Practice Address - Street 1:2287 MOWRY AVE
Practice Address - Street 2:STE C
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1622
Practice Address - Country:US
Practice Address - Phone:510-713-6559
Practice Address - Fax:510-713-6537
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3746213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E37460Medicare ID - Type Unspecified
CAU18551Medicare UPIN