1063849990 NPI number — MEDICAL ARTS DERMATOLOGY, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063849990 NPI number — MEDICAL ARTS DERMATOLOGY, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL ARTS DERMATOLOGY, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063849990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
401 HOSPITAL DR STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORSICANA
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75110-2415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-875-0413
Provider Business Mailing Address Fax Number:
903-872-4467

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 HOSPITAL DR STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORSICANA
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75110-2415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-875-0413
Provider Business Practice Location Address Fax Number:
903-872-4467
Provider Enumeration Date:
10/10/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BITLZ
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
903-875-0413

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  J6338 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1225001860 . This is a "NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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