Healthcare Provider Details

I. General information

NPI: 1093758237
Provider Name (Legal Business Name): NORTHEASTERN FOOT CARE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N MUSKOGEE
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

ONE PLAZA SOUTH PMB 317
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-3222
  • Fax: 918-456-3196
Mailing address:
  • Phone: 918-456-3222
  • Fax: 918-456-3196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JULIET C BURK
Title or Position: OWNER
Credential: DPM
Phone: 918-458-9888