Basic Information
| Provider Information | |||||||||
| NPI: | 1629135157 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOOGENDOORN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6048 LAKE WORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761353706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173361189 | ||||||||
| FaxNumber: | 8176988281 | ||||||||
| Practice Location | |||||||||
| Address1: | 6048 LAKE WORTH BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761353706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173361189 | ||||||||
| FaxNumber: | 8176988281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 11/03/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1844 | TX | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 198413002 | 05 | TX | MEDICAID | 198413003 | 05 | TX | MEDICAID | 198413001 | 05 | TX | MEDICAID | 198413004 | 05 | TX | MEDICAID |