Provider Demographics
NPI:1316482904
Name:DEFORMITY RECONSTRUCTION SPECIALISTS PLLC
Entity type:Organization
Organization Name:DEFORMITY RECONSTRUCTION SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EIDEH
Authorized Official - Middle Name:
Authorized Official - Last Name:ATWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:607-221-4229
Mailing Address - Street 1:1245 FALCON DR
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-1117
Mailing Address - Country:US
Mailing Address - Phone:607-221-4229
Mailing Address - Fax:
Practice Address - Street 1:1245 FALCON DR
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-1117
Practice Address - Country:US
Practice Address - Phone:607-221-4229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty