Provider Demographics
NPI:1457681785
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:D
Authorized Official - Last Name:PHELPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:903-593-0987
Mailing Address - Street 1:1761 TROUP HWY
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-5869
Mailing Address - Country:US
Mailing Address - Phone:903-593-0987
Mailing Address - Fax:903-597-5618
Practice Address - Street 1:1108 S BUFFALO ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-2304
Practice Address - Country:US
Practice Address - Phone:903-593-0987
Practice Address - Fax:903-597-5618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-08
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1636213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091707202Medicaid
TX0095BVMedicare PIN