MEDICARE: BERT EAGLE SHARP D.P.M.

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	1032	TX
2	213ER0200X	Radiology Podiatrist	1032	TX
3	213ES0000X	Sports Medicine Podiatrist	1032	TX
4	213ES0103X	Foot & Ankle Surgery Podiatrist	1032	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00A35L	OTHER	TX	BLUE CROSS BLUE SHIELD
2	4651102	OTHER	TX	AETNA
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	752573608	OTHER	TX	TAX ID

General Provider Information

NPI Number	:	1316900376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BERT EAGLE SHARP D.P.M.

Provider Business Mailing Address
First Line	:	613 N 4TH ST
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-6616
Country	:	US
Telephone Number	:	903-757-2300
Fax Number	:	903-758-0279

Provider Business Practice Location Address
First Line	:	613 N 4TH ST
Second Line	:
City	:	LONGVIEW
State	:	TX
Zip	:	75601-6616
Country	:	US
Telephone Number	:	903-757-2300
Fax Number	:	903-758-0279

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	09/16/2024

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Directions to “ BERT EAGLE SHARP D.P.M.” Practice Location

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