Provider Demographics
NPI:1275758351
Name:TRI LAKES PODIATRY PC
Entity Type:Organization
Organization Name:TRI LAKES PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:P
Authorized Official - Last Name:KORTE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-725-9995
Mailing Address - Street 1:PO BOX 870
Mailing Address - Street 2:300 WEST MT VERNON SUITE G
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-0870
Mailing Address - Country:US
Mailing Address - Phone:417-725-9995
Mailing Address - Fax:417-725-2985
Practice Address - Street 1:105 S RIDGECREST AVE
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-7807
Practice Address - Country:US
Practice Address - Phone:417-724-3100
Practice Address - Fax:417-725-2985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000165040213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00294967OtherRAILROAD MEDICARE
MO=========OtherTAX ID