Provider Demographics
NPI:1992988661
Name:MEYNARD M. NUSSBAUM DPM PA
Entity type:Organization
Organization Name:MEYNARD M. NUSSBAUM DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MEYNARD
Authorized Official - Middle Name:MORRIE
Authorized Official - Last Name:NUSSBAUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM PA
Authorized Official - Phone:713-781-0019
Mailing Address - Street 1:2500 FONDREN ROAD
Mailing Address - Street 2:SUITE 255
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-2313
Mailing Address - Country:US
Mailing Address - Phone:713-781-0019
Mailing Address - Fax:713-781-1112
Practice Address - Street 1:2500 FONDREN ROAD
Practice Address - Street 2:SUITE 255
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-2313
Practice Address - Country:US
Practice Address - Phone:713-781-0019
Practice Address - Fax:713-781-1112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0456213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX018796501Medicaid
TX0456OtherTX MEDICAL LICENSE
TX00265WMedicare PIN
TX0355030001Medicare NSC
TXT15079Medicare UPIN