Healthcare Provider Details

I. General information

NPI: 1093308983
Provider Name (Legal Business Name): WATER OAK FOOT AND ANKLE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2021
Last Update Date: 09/06/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2270 MATLOCK RD STE 104
MANSFIELD TX
76063-3710
US

IV. Provider business mailing address

2270 MATLOCK RD STE 104
MANSFIELD TX
76063-3710
US

V. Phone/Fax

Practice location:
  • Phone: 325-480-2063
  • Fax: 702-514-6292
Mailing address:
  • Phone: 325-480-2063
  • Fax: 702-514-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MATTHEW MCCABE
Title or Position: PRESIDENT
Credential: DPM
Phone: 702-630-1905