Provider Demographics
NPI:1053929430
Name:EXECUTIVE SOLE PODIATRY, PLLC
Entity type:Organization
Organization Name:EXECUTIVE SOLE PODIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANETRA
Authorized Official - Middle Name:SHARICE
Authorized Official - Last Name:MIRANDA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:866-925-5662
Mailing Address - Street 1:6445 FM 1463 RD STE 160-213
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-4027
Mailing Address - Country:US
Mailing Address - Phone:866-925-5662
Mailing Address - Fax:
Practice Address - Street 1:5373 W ALABAMA ST STE 204
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77056-5923
Practice Address - Country:US
Practice Address - Phone:866-925-5662
Practice Address - Fax:866-925-5662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-21
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric