Provider Demographics
NPI:1477194199
Name:DARREN ELENBURG DPM PC
Entity Type:Organization
Organization Name:DARREN ELENBURG DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:ELENBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-418-2676
Mailing Address - Street 1:609 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-2006
Mailing Address - Country:US
Mailing Address - Phone:405-418-2676
Mailing Address - Fax:405-418-2677
Practice Address - Street 1:507 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-5807
Practice Address - Country:US
Practice Address - Phone:405-418-2676
Practice Address - Fax:405-418-2677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DARREN ELENBURG DPM PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200120470AMedicaid