Provider Demographics
NPI:1780892877
Name:FOSTER, MIRELLE' JEANNE (MD)
Entity type:Individual
Prefix:
First Name:MIRELLE'
Middle Name:JEANNE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290142
Mailing Address - Street 2:
Mailing Address - City:KERRVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78029-0142
Mailing Address - Country:US
Mailing Address - Phone:830-258-7824
Mailing Address - Fax:830-896-9228
Practice Address - Street 1:551 HILL COUNTRY DR
Practice Address - Street 2:
Practice Address - City:KERRVILLE
Practice Address - State:TX
Practice Address - Zip Code:78028-6085
Practice Address - Country:US
Practice Address - Phone:830-258-7824
Practice Address - Fax:830-896-9228
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL3966208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8AJ225OtherBLUE CROSS BLUE SHIELD
TX152699801Medicaid
TX8577B6Medicare PIN
TX8AJ225OtherBLUE CROSS BLUE SHIELD