Provider Demographics
NPI:1861642654
Name:ELITE FOOTCARE CENTER PC
Entity Type:Organization
Organization Name:ELITE FOOTCARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:918-502-5300
Mailing Address - Street 1:6585 S YALE AVE
Mailing Address - Street 2:SUITE 1110
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8384
Mailing Address - Country:US
Mailing Address - Phone:918-502-5300
Mailing Address - Fax:918-502-5301
Practice Address - Street 1:6585 S YALE AVE
Practice Address - Street 2:SUITE 1110
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8384
Practice Address - Country:US
Practice Address - Phone:918-502-5300
Practice Address - Fax:918-502-5301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE 4700213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861642654Medicare NSC
OK1861642654Medicare NSC
CA6203150001Medicare NSC