Provider Demographics
NPI:1215020359
Name:PHILLIPS-DEINES, PENNY LEIGH (DPM)
Entity Type:Individual
Prefix:MRS
First Name:PENNY
Middle Name:LEIGH
Last Name:PHILLIPS-DEINES
Suffix:
Gender:F
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:PO BOX 6636
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466-6636
Mailing Address - Country:US
Mailing Address - Phone:361-992-4400
Mailing Address - Fax:361-992-4405
Practice Address - Street 1:5826 ESPLANADE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4173
Practice Address - Country:US
Practice Address - Phone:361-992-4400
Practice Address - Fax:361-992-4405
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1719213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176857401Medicaid
V05718Medicare UPIN
TXV05718Medicare UPIN
TX176857401Medicaid
TX6086550001Medicare NSC