Healthcare Provider Details

I. General information

NPI: 1316900376
Provider Name (Legal Business Name): BERT EAGLE SHARP D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 N 4TH ST
LONGVIEW TX
75601-6616
US

IV. Provider business mailing address

613 N 4TH ST
LONGVIEW TX
75601-6616
US

V. Phone/Fax

Practice location:
  • Phone: 903-757-2300
  • Fax: 903-758-0279
Mailing address:
  • Phone: 903-757-2300
  • Fax: 903-758-0279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1032
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number1032
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number1032
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number1032
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: