Provider Demographics
NPI:1598943219
Name:DR. ALAN ETTINGER DPM PA
Entity Type:Organization
Organization Name:DR. ALAN ETTINGER DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM PA
Authorized Official - Phone:817-738-1931
Mailing Address - Street 1:1001 12TH AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3928
Mailing Address - Country:US
Mailing Address - Phone:817-738-1931
Mailing Address - Fax:817-738-6990
Practice Address - Street 1:1001 12TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3928
Practice Address - Country:US
Practice Address - Phone:817-738-1931
Practice Address - Fax:817-738-6990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0469332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT13199Medicare UPIN
TX5189360001Medicare NSC
TX00N880Medicare PIN