1477194199 NPI number — DARREN ELENBURG DPM PC

Table of content: MRS. ANA LINDY CASTRO OT (NPI 1417605239)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477194199 NPI number — DARREN ELENBURG DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DARREN ELENBURG DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477194199
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
609 W MEMORIAL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73114-2006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-418-2676
Provider Business Mailing Address Fax Number:
405-418-2677

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
507 NE 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73160-5807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-418-2676
Provider Business Practice Location Address Fax Number:
405-418-2677
Provider Enumeration Date:
10/03/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ELENBURG
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
DEAN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
405-418-2676

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200120470A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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