Provider Demographics
NPI:1104926070
Name:TRAVIS, ERIC (DPM)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18800 MAIN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1707
Mailing Address - Country:US
Mailing Address - Phone:714-841-1963
Mailing Address - Fax:714-841-6919
Practice Address - Street 1:18800 MAIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-1707
Practice Address - Country:US
Practice Address - Phone:714-841-1963
Practice Address - Fax:714-841-6919
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4459213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E44590OtherB/S OF CAL-INDIVIDUAL ID
CA73-1649799OtherBILLING TAX ID
CAE4459Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER