Provider Demographics
NPI:1083667117
Name:HIGH PLAINS DERMATOLOGY CENTER, P.A.
Entity Type:Organization
Organization Name:HIGH PLAINS DERMATOLOGY CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-355-9866
Mailing Address - Street 1:4302 WOLFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-5959
Mailing Address - Country:US
Mailing Address - Phone:806-355-9866
Mailing Address - Fax:806-355-4004
Practice Address - Street 1:4302 WOLFLIN AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-5959
Practice Address - Country:US
Practice Address - Phone:806-355-9866
Practice Address - Fax:806-355-4004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX084882201Medicaid
TX084882201Medicaid