Provider Demographics
NPI:1164566246
Name:CENTRAL TEXAS DERMATOLOGY, PA
Entity Type:Organization
Organization Name:CENTRAL TEXAS DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER/CREDENTIALER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:BILLER
Authorized Official - Phone:512-327-8449
Mailing Address - Street 1:102 WESTLAKE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5373
Mailing Address - Country:US
Mailing Address - Phone:512-327-7779
Mailing Address - Fax:
Practice Address - Street 1:102 WESTLAKE DR
Practice Address - Street 2:#100
Practice Address - City:WEST LAKE HILLS
Practice Address - State:TX
Practice Address - Zip Code:78746
Practice Address - Country:US
Practice Address - Phone:512-327-7779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4405174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0064BMMedicare PIN