Provider Demographics
NPI:1992949564
Name:SURGICAL DERMATOLOGY ASSOCIATES
Entity type:Organization
Organization Name:SURGICAL DERMATOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:PERONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-554-6324
Mailing Address - Street 1:4851 S I 35 E
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CORINTH
Mailing Address - State:TX
Mailing Address - Zip Code:76210-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4851 S I 35 E
Practice Address - Street 2:SUITE 101
Practice Address - City:CORINTH
Practice Address - State:TX
Practice Address - Zip Code:76210-2348
Practice Address - Country:US
Practice Address - Phone:940-591-0900
Practice Address - Fax:940-220-6444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-27
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41532207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOA4879Medicare UPIN