Provider Demographics
NPI:1003350760
Name:WARTHAN DERMATOLOGY CENTER
Entity Type:Organization
Organization Name:WARTHAN DERMATOLOGY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-923-8220
Mailing Address - Street 1:4730 NE STALLINGS DR
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1615
Mailing Address - Country:US
Mailing Address - Phone:936-564-6107
Mailing Address - Fax:936-564-5124
Practice Address - Street 1:4730 NE STALLINGS DR
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1615
Practice Address - Country:US
Practice Address - Phone:936-564-6107
Practice Address - Fax:936-564-5124
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD8472207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB27426Medicare UPIN