Healthcare Provider Details

I. General information

NPI: 1881689560
Provider Name (Legal Business Name): ROBERT DANIEL PHELPS DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1828 E SOUTHEAST LOOP 323 STE 111
TYLER TX
75701-8314
US

IV. Provider business mailing address

1828 E SOUTHEAST LOOP 323 STE 111
TYLER TX
75701-8314
US

V. Phone/Fax

Practice location:
  • Phone: 903-593-0987
  • Fax: 903-592-3309
Mailing address:
  • Phone: 903-593-0987
  • Fax: 903-592-3309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number1636
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: