Provider Demographics
NPI:1144269853
Name:CHANDLER, GARY W (DPM)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:CHANDLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 SW ALSBURY BLVD STE 4
Mailing Address - Street 2:2696 PINNACLE
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-9201
Mailing Address - Country:US
Mailing Address - Phone:817-295-3799
Mailing Address - Fax:817-295-4530
Practice Address - Street 1:809 SW ALSBURY BLVD STE 4
Practice Address - Street 2:2696 PINNACLE
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-9201
Practice Address - Country:US
Practice Address - Phone:817-295-3799
Practice Address - Fax:817-295-4530
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0929213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX480021805OtherRAILROAD
TX127206401Medicaid
TX00JD55OtherBLUE CROSS BLUE SHEILD
TX127206401Medicaid
TXT12607Medicare UPIN
TXP00131878Medicare Oscar/Certification
TX1172200001Medicare NSC