1457681785 NPI number — FOOT CLINIC OF EAST TEXAS, PC

Table of content: (NPI 1457681785)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457681785 NPI number — FOOT CLINIC OF EAST TEXAS, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT CLINIC OF EAST TEXAS, 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:
1457681785
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1828 E SOUTHEAST LOOP 323 STE 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYLER
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75701-8314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-593-0987
Provider Business Mailing Address Fax Number:
903-592-3309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1108 S BUFFALO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75103-2304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-593-0987
Provider Business Practice Location Address Fax Number:
903-592-3309
Provider Enumeration Date:
01/08/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PHELPS
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER/DPM
Authorized Official Telephone Number:
903-593-0987

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  L1636 , 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: 001752916 . This is a "UHC ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 091707203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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