Provider Demographics
NPI:1992813570
Name:DERMATOLOGY SPECIALISTS, PA
Entity type:Organization
Organization Name:DERMATOLOGY SPECIALISTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MGR
Authorized Official - Prefix:
Authorized Official - First Name:SANDALEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:KRUEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-699-0000
Mailing Address - Street 1:3005 E RENNER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-3505
Mailing Address - Country:US
Mailing Address - Phone:972-699-0000
Mailing Address - Fax:972-699-0004
Practice Address - Street 1:3005 E. RENNER ROAD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082
Practice Address - Country:US
Practice Address - Phone:792-699-0000
Practice Address - Fax:972-699-0004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0877207N00000X
207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00362YMedicare ID - Type UnspecifiedGROUP MEDICARE NUMBER