Provider Demographics
NPI:1376509844
Name:MENACKER, LARRY W (DPM)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:MENACKER
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 1:2416 E ALLEGHENY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19134-4403
Mailing Address - Country:US
Mailing Address - Phone:215-843-2330
Mailing Address - Fax:215-848-6760
Practice Address - Street 1:2416 E ALLEGHENY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-4403
Practice Address - Country:US
Practice Address - Phone:215-843-2330
Practice Address - Fax:215-848-6760
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC001941L213E00000X
NJMD1184213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0016086790004Medicaid
PA0016086790004Medicaid
PA544104Medicare ID - Type Unspecified
NJ735706Medicare ID - Type Unspecified