Provider Demographics
NPI:1184688566
Name:FOOT CLINIC OF EAST TEXAS PC
Entity Type:Organization
Organization Name:FOOT CLINIC OF EAST TEXAS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:903-593-0987
Mailing Address - Street 1:1828 E SE LOOP 323 STE 111
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8314
Mailing Address - Country:US
Mailing Address - Phone:903-593-0987
Mailing Address - Fax:903-592-3309
Practice Address - Street 1:1828 ESE LOOP323 STE 111
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8314
Practice Address - Country:US
Practice Address - Phone:903-593-0987
Practice Address - Fax:903-592-3309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091707202Medicaid
TX4356860001Medicare NSC
TX0095BVMedicare PIN