Provider Demographics
NPI:1750550489
Name:FOOT CARE OF NORTHEAST ARKANSAS PA
Entity type:Organization
Organization Name:FOOT CARE OF NORTHEAST ARKANSAS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDY
Authorized Official - Middle Name:LLOYD
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:870-933-8900
Mailing Address - Street 1:PO BOX 1984
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1984
Mailing Address - Country:US
Mailing Address - Phone:870-933-8900
Mailing Address - Fax:870-933-2611
Practice Address - Street 1:406 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3108
Practice Address - Country:US
Practice Address - Phone:870-933-8900
Practice Address - Fax:870-933-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR163213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
16888000000OtherQUALCHOICE
AR167681748Medicaid
480034780OtherRR MEDICARE
AR5F963OtherMEDICARE
5T344OtherBCBS
AR130246748Medicaid
5T344Medicare PIN
AR5F963OtherMEDICARE
16888000000OtherQUALCHOICE