Provider Demographics
NPI:1063178846
Name:DALLAS METRO SKIN HEALTH PA
Entity type:Organization
Organization Name:DALLAS METRO SKIN HEALTH PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:KHORSANDI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:347-661-6934
Mailing Address - Street 1:810 WAUGH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-2013
Mailing Address - Country:US
Mailing Address - Phone:347-661-6934
Mailing Address - Fax:
Practice Address - Street 1:4252A OAK LAWN AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-2312
Practice Address - Country:US
Practice Address - Phone:214-253-8690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1194017277OtherNPI