Provider Demographics
NPI:1962878843
Name:PRESTIGE DERMATOLOGY PLLC
Entity type:Organization
Organization Name:PRESTIGE DERMATOLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-718-3571
Mailing Address - Street 1:621 SW JOHNSON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-5833
Mailing Address - Country:US
Mailing Address - Phone:817-766-7421
Mailing Address - Fax:817-447-8100
Practice Address - Street 1:264 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4575
Practice Address - Country:US
Practice Address - Phone:817-766-7421
Practice Address - Fax:817-447-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-14
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX449761Medicare PIN