Provider Demographics
NPI:1417934811
Name:KELNER, EVAN BRET (DPM)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:BRET
Last Name:KELNER
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 1:1398 OCEAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4523
Mailing Address - Country:US
Mailing Address - Phone:732-988-0070
Mailing Address - Fax:732-988-0250
Practice Address - Street 1:1398 OCEAN AVENUE
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-4523
Practice Address - Country:US
Practice Address - Phone:732-988-0070
Practice Address - Fax:732-988-0250
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-27
Last Update Date:2013-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01974213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT51415Medicare UPIN