Healthcare Provider Details

I. General information

NPI: 1093786998
Provider Name (Legal Business Name): GLENN MICHAEL WEINRAUB DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 01/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

IV. Provider business mailing address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

V. Phone/Fax

Practice location:
  • Phone: 510-454-1000
  • Fax: 540-772-3785
Mailing address:
  • Phone: 510-454-1000
  • Fax: 540-772-3785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE4043
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: