Healthcare Provider Details

I. General information

NPI: 1346285780
Provider Name (Legal Business Name): ELLIOTT LYLE WENGER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 SUMMIT ST 101
OAKLAND CA
94609-3423
US

IV. Provider business mailing address

6425 OAKWOOD DR
OAKLAND CA
94611-1350
US

V. Phone/Fax

Practice location:
  • Phone: 510-832-3137
  • Fax: 510-338-0760
Mailing address:
  • Phone: 510-832-3137
  • Fax: 510-338-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE1759
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: