Provider Demographics
NPI:1386164077
Name:KELLNER, SAMUEL (DPM)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:KELLNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 GRANDVIEW AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2517
Mailing Address - Country:US
Mailing Address - Phone:203-753-2048
Mailing Address - Fax:203-753-5891
Practice Address - Street 1:171 GRANDVIEW AVE STE 104
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2517
Practice Address - Country:US
Practice Address - Phone:203-753-2048
Practice Address - Fax:203-753-5891
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001121213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery