Provider Demographics
NPI:1194923599
Name:NASSAU BAY DERMATOLOGY PA
Entity type:Organization
Organization Name:NASSAU BAY DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-286-4455
Mailing Address - Street 1:390 E MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-4321
Mailing Address - Country:US
Mailing Address - Phone:281-286-4455
Mailing Address - Fax:281-286-3366
Practice Address - Street 1:390 E MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-4321
Practice Address - Country:US
Practice Address - Phone:281-286-4455
Practice Address - Fax:281-286-3366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123936001Medicaid
TX123936001Medicaid