Provider Demographics
NPI:1063864726
Name:SOUTHEAST TEXAS DERMATOLOGY CLINIC, PLLC
Entity Type:Organization
Organization Name:SOUTHEAST TEXAS DERMATOLOGY CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BAYLOR
Authorized Official - Middle Name:W
Authorized Official - Last Name:KURTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-729-2262
Mailing Address - Street 1:2300 HIGHWAY 365 STE 670
Mailing Address - Street 2:
Mailing Address - City:NEDERLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77627-6292
Mailing Address - Country:US
Mailing Address - Phone:409-729-2262
Mailing Address - Fax:409-729-2449
Practice Address - Street 1:2300 HIGHWAY 365 STE 670
Practice Address - Street 2:
Practice Address - City:NEDERLAND
Practice Address - State:TX
Practice Address - Zip Code:77627-6292
Practice Address - Country:US
Practice Address - Phone:409-729-2262
Practice Address - Fax:409-729-2449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2016-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty