Basic Information
| Provider Information | |||||||||
| NPI: | 1750531034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOULIOTIS | ||||||||
| FirstName: | NOLASKA | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TARDENCILLA | ||||||||
| OtherFirstName: | NOLASKA | ||||||||
| OtherMiddleName: | I | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014015 | ||||||||
| FaxNumber: | 5129013935 | ||||||||
| Practice Location | |||||||||
| Address1: | 12221 N MOPAC EXPY | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787582401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5129014015 | ||||||||
| FaxNumber: | 5129013935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2008 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 1985 | TX | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 1985 | TX | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0103X | 016.005371 | IL | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213ES0131X | 1985 | TX | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00986695 | 01 | RAILROAD MEDICARE | OTHER | 285495201 | 05 | TX | MEDICAID |