1457778474 NPI number — UNITED DERMATOLOGY ASSOCIATES OF BURLESON, PLLC

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 1457778474 NPI number — UNITED DERMATOLOGY ASSOCIATES OF BURLESON, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNITED DERMATOLOGY ASSOCIATES OF BURLESON, PLLC
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:
6
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:
1457778474
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 E BROAD ST
Provider Second Line Business Mailing Address:
SUITE 124
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-6410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-261-1122
Provider Business Mailing Address Fax Number:
817-261-1123

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 NE ALSBURY BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BURLESON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76028-2641
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-261-1122
Provider Business Practice Location Address Fax Number:
817-261-1123
Provider Enumeration Date:
03/27/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BARRON
Authorized Official First Name:
ERICA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
817-261-1122

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  M1144 , 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)





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