Provider Demographics
NPI:1346285780
Name:WENGER, ELLIOTT LYLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:LYLE
Last Name:WENGER
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 1:6425 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-1350
Mailing Address - Country:US
Mailing Address - Phone:510-832-3137
Mailing Address - Fax:510-338-0760
Practice Address - Street 1:2929 SUMMIT ST
Practice Address - Street 2:101
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3423
Practice Address - Country:US
Practice Address - Phone:510-832-3137
Practice Address - Fax:510-338-0760
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1759213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E17591Medicaid
CA000E17590Medicaid
CA000E17590Medicare ID - Type Unspecified
CA000E17591Medicaid
CA000E17590Medicaid