Provider Demographics
NPI:1265562623
Name:TRAVELING FOOT DOCTOR, P.C.
Entity type:Organization
Organization Name:TRAVELING FOOT DOCTOR, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KLECKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:907-694-7942
Mailing Address - Street 1:PO BOX 772394
Mailing Address - Street 2:22434 EAGLE GLACIER LOOP
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-2394
Mailing Address - Country:US
Mailing Address - Phone:907-694-7942
Mailing Address - Fax:
Practice Address - Street 1:22434 EAGLE GLACIER LOOP
Practice Address - Street 2:P.O. B. 772394-2394
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-9531
Practice Address - Country:US
Practice Address - Phone:907-694-7942
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3626213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKT90807Medicare UPIN