Provider Demographics
NPI:1962219535
Name:BLUE RIBBON DERMATOLOGY PLLC
Entity type:Organization
Organization Name:BLUE RIBBON DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NADER
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUL-FETTOUH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-681-5538
Mailing Address - Street 1:1150 N WATTERS RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 N WATTERS RD STE 105
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5536
Practice Address - Country:US
Practice Address - Phone:214-843-1343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2025-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty