Provider Demographics
NPI:1689818684
Name:CENTRAL TEXAS FOOT SPECIALIST PA
Entity Type:Organization
Organization Name:CENTRAL TEXAS FOOT SPECIALIST PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:KUKLA
Authorized Official - Last Name:PIETZSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:512-819-4555
Mailing Address - Street 1:3316 WILLIAMS DR STE 120
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3316 WILLIAMS DR STE 120
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2891
Practice Address - Country:US
Practice Address - Phone:512-819-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1667213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A4523Medicare PIN
TX8F21698Medicare PIN
TX6257000001Medicare NSC