Provider First Line Business Practice Location Address:
313 EAST 12TH ST
Provider Second Line Business Practice Location Address:
SUITE 103 DERMATOLOGY
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78701-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-324-9650
Provider Business Practice Location Address Fax Number:
512-324-9653
Provider Enumeration Date:
01/24/2006