Provider Demographics
NPI:1821210188
Name:PRO-HEALTH PODIATRY P.A.
Entity Type:Organization
Organization Name:PRO-HEALTH PODIATRY P.A.
Other - Org Name:PRO-HEALTH PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:FORBES-BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:817-459-1400
Mailing Address - Street 1:4621 SOUTH COOPER STREET
Mailing Address - Street 2:#131-281
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5866
Mailing Address - Country:US
Mailing Address - Phone:817-459-1400
Mailing Address - Fax:817-459-1401
Practice Address - Street 1:107 EAST PARK ROW DRIVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-4426
Practice Address - Country:US
Practice Address - Phone:817-459-1400
Practice Address - Fax:817-459-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1529213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6346240001Medicare NSC