Provider Demographics
NPI:1023297785
Name:PODIATRY CLINICS P,A,
Entity type:Organization
Organization Name:PODIATRY CLINICS P,A,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:REZENDES
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:210-655-9965
Mailing Address - Street 1:12413 JUDSON RD
Mailing Address - Street 2:STE 120
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3202
Mailing Address - Country:US
Mailing Address - Phone:210-655-9965
Mailing Address - Fax:210-655-9985
Practice Address - Street 1:12413 JUDSON RD
Practice Address - Street 2:STE 120
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3202
Practice Address - Country:US
Practice Address - Phone:210-655-9965
Practice Address - Fax:210-655-9985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1289213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178288001Medicaid
0031HQOtherBCBS
TX5277470001Medicare NSC
TX00841TMedicare PIN