Provider Demographics
NPI:1790730380
Name:PELLERSELS, JEFFREY CRAIG (DPM)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CRAIG
Last Name:PELLERSELS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:FOOT
Other - Middle Name:
Other - Last Name:& ANKLE CLINICS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:563 BIELENBERG DR
Mailing Address - Street 2:SUITE 150
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-4425
Mailing Address - Country:US
Mailing Address - Phone:651-457-4665
Mailing Address - Fax:651-457-3115
Practice Address - Street 1:563 BIELENBERG DR
Practice Address - Street 2:SUITE 150
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-4425
Practice Address - Country:US
Practice Address - Phone:651-457-4665
Practice Address - Fax:651-457-3115
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN473213E00000X, 213ES0103X
WI668-025213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN944325800Medicaid
WI43214500Medicaid
WI43214500Medicaid
WI000086579Medicare PIN
MN944325800Medicaid
WI000086552Medicare PIN