Provider Demographics
NPI:1629174446
Name:FOOTCARE PA
Entity Type:Organization
Organization Name:FOOTCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:MASHIGIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-939-1757
Mailing Address - Street 1:4333 N JOSEY LN
Mailing Address - Street 2:206
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75010-4629
Mailing Address - Country:US
Mailing Address - Phone:972-939-1757
Mailing Address - Fax:972-939-1682
Practice Address - Street 1:4333 N JOSEY LN
Practice Address - Street 2:206
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75010-4629
Practice Address - Country:US
Practice Address - Phone:972-939-1757
Practice Address - Fax:972-939-1682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0014CZOtherBCBS GROUP PROV #
TX080689501Medicaid
TX5160860002Medicare NSC
TX00497KMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER