Healthcare Provider Details

I. General information

NPI: 1831222090
Provider Name (Legal Business Name): DAVID JASON ELLENBOGEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 02/14/2023
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10035 PARK CEDAR DR STE 100
CHARLOTTE NC
28210-8910
US

IV. Provider business mailing address

10035 PARK CEDAR DR STE 100
CHARLOTTE NC
28210-8910
US

V. Phone/Fax

Practice location:
  • Phone: 704-442-9011
  • Fax: 704-625-9484
Mailing address:
  • Phone: 704-442-9011
  • Fax: 704-625-9484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number615
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number615
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number615
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: