Provider Demographics
NPI:1417238999
Name:INNOVATIVE DERMATOLOGY P A
Entity type:Organization
Organization Name:INNOVATIVE DERMATOLOGY P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SEEMAL
Authorized Official - Middle Name:R
Authorized Official - Last Name:DESAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-919-3500
Mailing Address - Street 1:5425 W SPRING CREEK PKWY
Mailing Address - Street 2:SUITE 265
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-4236
Mailing Address - Country:US
Mailing Address - Phone:214-919-3500
Mailing Address - Fax:214-919-3501
Practice Address - Street 1:5425 W SPRING CREEK PKWY
Practice Address - Street 2:SUITE 265
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-4236
Practice Address - Country:US
Practice Address - Phone:214-919-3500
Practice Address - Fax:214-919-3501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN3612207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty