Provider Demographics
NPI:1467637405
Name:DIANE M PHALEN
Entity Type:Organization
Organization Name:DIANE M PHALEN
Other - Org Name:SAN MARCOS FOOT AND ANKLE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PHALEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:512-396-0808
Mailing Address - Street 1:1305 WONDER WORLD DR
Mailing Address - Street 2:304
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7546
Mailing Address - Country:US
Mailing Address - Phone:512-396-0808
Mailing Address - Fax:512-396-0804
Practice Address - Street 1:1305 WONDER WORLD DR
Practice Address - Street 2:304
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7546
Practice Address - Country:US
Practice Address - Phone:512-396-0808
Practice Address - Fax:512-396-0804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0992213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018653801Medicaid
TXT15276Medicare UPIN
TX018653801Medicaid
TX00DC53Medicare PIN