{
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"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "FALL CREEK FOOT & ANKLE PLLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
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"NameSuffix": null,
"Credential": null,
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"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "9701 N SAM HOUSTON PKWY E",
"SecondLineMailingAddress": "SUITE 150",
"MailingAddressCityName": "HUMBLE",
"MailingAddressStateName": "TX",
"MailingAddressPostalCode": "77396-4693",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "281-973-5237",
"MailingAddressFaxNumber": "832-412-2016",
"FirstLinePracticeLocationAddress": "9701 N SAM HOUSTON PKWY E",
"SecondLinePracticeLocationAddress": "SUITE 150",
"PracticeLocationAddressCityName": "HUMBLE",
"PracticeLocationAddressStateName": "TX",
"PracticeLocationAddressPostalCode": "77396-4693",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "281-973-5237",
"PracticeLocationAddressFaxNumber": "832-412-2016",
"EnumerationDate": "07/20/2016",
"LastUpdateDate": "01/13/2017",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BODEKER",
"AuthorizedOfficialFirstName": "TRAVIS",
"AuthorizedOfficialMiddleName": "SCOTT",
"AuthorizedOfficialTitle": "OWNER",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "DPM",
"AuthorizedOfficialTelephoneNumber": "281-973-5237",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "213ES0103X",
"TaxonomyName": "Foot & Ankle Surgery Podiatrist",
"LicenseNumber": "2147",
"LicenseNumberStateCode": "TX",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": {
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
}
}
}