Healthcare Provider Details

I. General information

NPI: 1225137185
Provider Name (Legal Business Name): EAST TEXAS PODIATRY ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 E IDEL SUITE A
TYLER TX
75701
US

IV. Provider business mailing address

1028 E IDEL SUITE A
TYLER TX
75701
US

V. Phone/Fax

Practice location:
  • Phone: 903-593-1749
  • Fax: 903-593-1487
Mailing address:
  • Phone: 903-593-1749
  • Fax: 903-593-1487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT A BOUDREAU
Title or Position: OWNER
Credential: DPM
Phone: 903-593-1749