Provider Demographics
NPI:1134286024
Name:REDISKE, WILLIAM ROBERT (DPM)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:ROBERT
Last Name:REDISKE
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 1:2300 S CLEAR CREEK RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-4984
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 S CLEAR CREEK RD
Practice Address - Street 2:SUITE 203
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-4984
Practice Address - Country:US
Practice Address - Phone:254-634-8818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1546213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126002803Medicaid
TXBR8521800OtherDRUG ENFORCEMENT ADM #
TX00850NMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER