Provider Demographics
NPI:1497988828
Name:THE FOOT DOCTORS, P.C.
Entity Type:Organization
Organization Name:THE FOOT DOCTORS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-883-1881
Mailing Address - Street 1:929 E MONTCLAIR ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5068
Mailing Address - Country:US
Mailing Address - Phone:417-883-1881
Mailing Address - Fax:417-883-4844
Practice Address - Street 1:1015 HIGHWAY 248
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-8001
Practice Address - Country:US
Practice Address - Phone:417-883-1881
Practice Address - Fax:417-883-4844
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE FOOT DOCTORS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO990001420OtherMEDICARE