Provider Demographics
NPI:1083769467
Name:COCKERELL DERMATOLOGY CONSULTING SERVICES, PA
Entity Type:Organization
Organization Name:COCKERELL DERMATOLOGY CONSULTING SERVICES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-379-5381
Mailing Address - Street 1:25 HIGHLAND PARK VLG
Mailing Address - Street 2:BOX 100-335
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-2789
Mailing Address - Country:US
Mailing Address - Phone:817-379-5381
Mailing Address - Fax:
Practice Address - Street 1:2110 RESEARCH ROW
Practice Address - Street 2:SUITE 100
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-2520
Practice Address - Country:US
Practice Address - Phone:214-530-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF9311207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR127246001Medicaid
TX60RQOtherBLUE CROSS
TX137371406Medicaid
TXA63878Medicare UPIN
AR127246001Medicaid