1114086659 NPI number — EAST TEXAS FOOT ASSOCIATES

Table of content: (NPI 1114086659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114086659 NPI number — EAST TEXAS FOOT ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST TEXAS FOOT ASSOCIATES
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:
1114086659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 S. JOHN REDDITT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUFKIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
936-632-5252
Provider Business Mailing Address Fax Number:
936-632-5284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S. JOHN REDDITT DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUFKIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75904
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
936-632-5252
Provider Business Practice Location Address Fax Number:
936-632-5284
Provider Enumeration Date:
12/08/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CORSE
Authorized Official First Name:
EDDY
Authorized Official Middle Name:
GENE
Authorized Official Title or Position:
DPM
Authorized Official Telephone Number:
936-632-5252

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  1590 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213E00000X , with the licence number: 0540 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14HZ . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 151320201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 373459201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".