Provider Demographics
NPI:1215160312
Name:BAYSIDE DERMATOLOGY PA
Entity type:Organization
Organization Name:BAYSIDE DERMATOLOGY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:806-771-1166
Mailing Address - Street 1:1321 WATERS EDGE DR
Mailing Address - Street 2:SUITE 1003
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-2567
Mailing Address - Country:US
Mailing Address - Phone:806-771-1166
Mailing Address - Fax:806-687-0380
Practice Address - Street 1:1321 WATERS EDGE DR
Practice Address - Street 2:SUITE 1003
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-2567
Practice Address - Country:US
Practice Address - Phone:806-771-1166
Practice Address - Fax:806-687-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-24
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A5324Medicare PIN