MEDICARE: FOOT CLINIC OF EAST TEXAS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213E00000X	Podiatrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184688566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT CLINIC OF EAST TEXAS PC

Provider Business Mailing Address
First Line	:	1828 E SOUTHEAST LOOP 323 STE 111
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-8314
Country	:	US
Telephone Number	:	903-593-0987
Fax Number	:	903-592-3309

Provider Business Practice Location Address
First Line	:	1828 E SOUTHEAST LOOP 323 STE 111
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-8314
Country	:	US
Telephone Number	:	903-593-0987
Fax Number	:	903-592-3309

Authorized Official
Title or Position	:	OWNER/DPM
Name	:	DR. ROBERT DANIEL PHELPS
Credential	:	DPM
Telephone Number	:	903-593-0987

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	05/13/2024

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