Provider Demographics
NPI:1629135157
Name:HOOGENDOORN, KYLE E (DPM)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:E
Last Name:HOOGENDOORN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6048 LAKE WORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3706
Mailing Address - Country:US
Mailing Address - Phone:817-336-1189
Mailing Address - Fax:817-698-8281
Practice Address - Street 1:6048 LAKE WORTH BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3706
Practice Address - Country:US
Practice Address - Phone:817-336-1189
Practice Address - Fax:817-698-8281
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1844213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198413002Medicaid
TX198413003Medicaid
TX198413001Medicaid
TX198413004Medicaid
U72775Medicare UPIN
TX8L2283Medicare PIN
TX198413003Medicaid
TX198413001Medicaid
TX198413004Medicaid