Provider Demographics
NPI:1225137185
Name:EAST TEXAS PODIATRY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:EAST TEXAS PODIATRY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:903-593-1749
Mailing Address - Street 1:1028 E IDEL
Mailing Address - Street 2:SUITE A
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-593-1749
Mailing Address - Fax:903-593-1487
Practice Address - Street 1:1028 E IDEL
Practice Address - Street 2:SUITE A
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-593-1749
Practice Address - Fax:903-593-1487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2009-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX480028507OtherRAILROAD MEDICARE
TX5594780001OtherPALMETTO DME
TX5594780001Medicare NSC
TX480028507OtherRAILROAD MEDICARE
TX5594780001OtherPALMETTO DME
TX480028507Medicare PIN