Provider Demographics
NPI:1043795743
Name:PRISM DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:PRISM DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-258-7499
Mailing Address - Street 1:925 E SOUTHLAKE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1476
Mailing Address - Country:US
Mailing Address - Phone:940-393-9582
Mailing Address - Fax:
Practice Address - Street 1:925 E SOUTHLAKE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-1476
Practice Address - Country:US
Practice Address - Phone:940-393-9582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty