Provider Demographics
NPI:1699120048
Name:PALO DURO DERMATOLOGY, PLLC
Entity type:Organization
Organization Name:PALO DURO DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:806-553-0185
Mailing Address - Street 1:PO BOX 1638
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-1638
Mailing Address - Country:US
Mailing Address - Phone:806-488-2176
Mailing Address - Fax:
Practice Address - Street 1:2005 N 2ND AVE STE D
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-2545
Practice Address - Country:US
Practice Address - Phone:806-553-0185
Practice Address - Fax:806-853-6630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX45D2117683OtherCLIA