Provider Demographics
NPI:1831222090
Name:ELLENBOGEN, DAVID JASON (DPM)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JASON
Last Name:ELLENBOGEN
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 1:10035 PARK CEDAR DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8910
Mailing Address - Country:US
Mailing Address - Phone:704-442-9011
Mailing Address - Fax:704-625-9484
Practice Address - Street 1:10035 PARK CEDAR DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8910
Practice Address - Country:US
Practice Address - Phone:704-442-9011
Practice Address - Fax:704-625-9484
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC615213EP1101X, 213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1342Medicare PIN