Provider Demographics
NPI:1659865806
Name:FUSION FOOT AND ANKLE, PLLC
Entity Type:Organization
Organization Name:FUSION FOOT AND ANKLE, PLLC
Other - Org Name:FUSION FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOODY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANKERIOUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-494-0566
Mailing Address - Street 1:8751 CAMP BOWIE WEST BLVD STE 123
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-6100
Mailing Address - Country:US
Mailing Address - Phone:817-494-0566
Mailing Address - Fax:817-612-3157
Practice Address - Street 1:8751 CAMP BOWIE WEST BLVD STE 123
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-6100
Practice Address - Country:US
Practice Address - Phone:817-494-0566
Practice Address - Fax:817-612-3157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-20
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty