Provider Demographics
NPI:1033706445
Name:JERDAN DERMATOLOGY LASER AND AESTHETIC INSTITUTE PLLC
Entity Type:Organization
Organization Name:JERDAN DERMATOLOGY LASER AND AESTHETIC INSTITUTE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JERDAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-212-2280
Mailing Address - Street 1:1211 N SHARTEL AVE STE 802
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2425
Mailing Address - Country:US
Mailing Address - Phone:405-212-2280
Mailing Address - Fax:405-493-9200
Practice Address - Street 1:1211 N SHARTEL AVE STE 802
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2425
Practice Address - Country:US
Practice Address - Phone:405-212-2280
Practice Address - Fax:405-493-9200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-31
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty