Provider Demographics
NPI:1396050449
Name:FAMILY FOOT CLINIC PC
Entity type:Organization
Organization Name:FAMILY FOOT CLINIC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:972-270-7627
Mailing Address - Street 1:1675 REPUBLIC PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6903
Mailing Address - Country:US
Mailing Address - Phone:972-270-7627
Mailing Address - Fax:972-270-7759
Practice Address - Street 1:3142 HORIZON RD
Practice Address - Street 2:STE 100
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75032-7809
Practice Address - Country:US
Practice Address - Phone:972-772-9600
Practice Address - Fax:972-772-9601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-13
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0425213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y938Medicare PIN