Provider Demographics
NPI:1376597443
Name:EHRENBERG, DOUGLAS ALAN (DPM)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:ALAN
Last Name:EHRENBERG
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 1:52 MOHAWK AVE
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1033
Mailing Address - Country:US
Mailing Address - Phone:415-385-7587
Mailing Address - Fax:
Practice Address - Street 1:52 MOHAWK AVE
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1033
Practice Address - Country:US
Practice Address - Phone:415-385-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-21
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3463213E00000X, 213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE3463OtherSTATE LIC.
CA000E34631Medicare ID - Type UnspecifiedMEDICARE ID
CAT11698Medicare UPIN