Provider Demographics
NPI:1356336614
Name:ITENBERG, ILANA (DPM)
Entity type:Individual
Prefix:
First Name:ILANA
Middle Name:
Last Name:ITENBERG
Suffix:
Gender:F
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:PO BOX 3677
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03061-3677
Mailing Address - Country:US
Mailing Address - Phone:603-577-7900
Mailing Address - Fax:603-577-7972
Practice Address - Street 1:17 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3956
Practice Address - Country:US
Practice Address - Phone:603-577-3230
Practice Address - Fax:603-577-3234
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005742213ES0131X
CT000800213ES0131X
NJ25MD00283300213ES0131X
NH0317213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6298914OtherGHI
NY9533745OtherCIGNA
NYPJ4082OtherBCBS
NY2701877OtherUNITED HEALTH CARE
NY02459745Medicaid
NYP3060948OtherOXFORD
NY161658POtherHIP
NY06Other1199
NY2701877OtherUNITED HEALTH CARE
PH6741Medicare ID - Type Unspecified