Provider Demographics
NPI:1083729156
Name:RED OAK PODIATRY, PC
Entity Type:Organization
Organization Name:RED OAK PODIATRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:LYKKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:281-537-1999
Mailing Address - Street 1:17070 RED OAK DR STE 209
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2615
Mailing Address - Country:US
Mailing Address - Phone:281-537-1999
Mailing Address - Fax:281-537-1978
Practice Address - Street 1:17070 RED OAK DR
Practice Address - Street 2:STE 209
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2615
Practice Address - Country:US
Practice Address - Phone:281-537-1999
Practice Address - Fax:281-537-1978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0645213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1553091-01Medicaid
4283440001Medicare NSC
TX00041TMedicare PIN