Provider Demographics
NPI:1003940677
Name:DERMATOLOGY ASSOCIATES OF UPTOWN, PA
Entity Type:Organization
Organization Name:DERMATOLOGY ASSOCIATES OF UPTOWN, PA
Other - Org Name:AFTERGUT DERMATOLOGY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:S
Authorized Official - Last Name:AFTERGUT
Authorized Official - Suffix:
Authorized Official - Credentials:MDPA
Authorized Official - Phone:972-283-8979
Mailing Address - Street 1:610 UPTOWN BLVD. #102
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-3507
Mailing Address - Country:US
Mailing Address - Phone:972-283-8979
Mailing Address - Fax:972-283-8988
Practice Address - Street 1:610 UPTOWN BLVD. #102
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-3507
Practice Address - Country:US
Practice Address - Phone:972-283-8979
Practice Address - Fax:972-283-8988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-15
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164468401Medicaid
TX163664902Medicaid
TXP00043595Medicare PIN
TXH86484Medicare UPIN
TX00333VMedicare PIN