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General NPI Number Information
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NPI Number | 1457681785
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Entity Type | Organization
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Legal Business Name | FOOT CLINIC OF EAST TEXAS, PC
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Dates
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Enumeration Date | 01/08/2010
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Last Update Date | 07/22/2024
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Provider Practice Location Address
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Address Line | 1108 S BUFFALO ST
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City | CANTON
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State | TX
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Zip | 75103-2304
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Country | US
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Telephone | 903-593-0987
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Fax | 903-592-3309
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Provider Business Mailing Address
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Address Line | 1828 E SOUTHEAST LOOP 323 STE 111
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City | TYLER
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State | TX
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Zip | 75701-8314
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Country | US
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Telephone | 903-593-0987
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Fax | 903-592-3309
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Authorized Official
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Title or Position | OWNER/DPM
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Name | DR. ROBERT D PHELPS
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Credential | DPM
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Telephone | 903-593-0987
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | L1636
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License Number State | TX
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