Healthcare Provider Details

I. General information

NPI: 1417970492
Provider Name (Legal Business Name): ELAINE ALLEN DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 FOUR LEAF LN STE 11A
CHARLOTTESVILLE VA
22903-9203
US

IV. Provider business mailing address

325 FOUR LEAF LN STE 11A
CHARLOTTESVILLE VA
22903-9203
US

V. Phone/Fax

Practice location:
  • Phone: 434-242-8550
  • Fax: 434-205-4637
Mailing address:
  • Phone: 434-242-8550
  • Fax: 434-205-4637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000744
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number000744
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000744
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: