MEDICARE: FOOT AND ANKLE CLINIC OF WESTERN OKLAHOMA

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	230	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00162625	OTHER	OK	RAILROAD MEDICARE
3	200522085	OTHER	OK	MEDICARE GROUP

Other Identifiers

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

General Provider Information

NPI Number	:	1518132885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOOT AND ANKLE CLINIC OF WESTERN OKLAHOMA

Provider Business Mailing Address
First Line	:	800 FRISCO AVE
Second Line	:
City	:	CLINTON
State	:	OK
Zip	:	73601-3306
Country	:	US
Telephone Number	:	580-323-5800
Fax Number	:	580-323-5802

Provider Business Practice Location Address
First Line	:	1221 COLORADO AVE
Second Line	:	STE C
City	:	ELK CITY
State	:	OK
Zip	:	73644-2800
Country	:	US
Telephone Number	:	580-225-9955
Fax Number	:	580-225-9954

Authorized Official
Title or Position	:	OWNER
Name	:	DR. BRADLEY DEWAYNE NELSON
Credential	:	DPM
Telephone Number	:	580-323-5800

Provider Enumeration Date	:	04/28/2008
Last Update Date	:	04/28/2008

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Directions to “FOOT AND ANKLE CLINIC OF WESTERN OKLAHOMA ” Practice Location

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