Provider Demographics
NPI:1164859229
Name:DERMATOLOGY & COSMETIC SURGERY ASSOCIATES PA
Entity Type:Organization
Organization Name:DERMATOLOGY & COSMETIC SURGERY ASSOCIATES PA
Other - Org Name:LIFEWAY DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:PHAN
Authorized Official - Last Name:NIKKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-960-1311
Mailing Address - Street 1:1001 WEST LOOP S
Mailing Address - Street 2:STE 813
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-9084
Mailing Address - Country:US
Mailing Address - Phone:713-960-1311
Mailing Address - Fax:713-960-1325
Practice Address - Street 1:1001 WEST LOOP S
Practice Address - Street 2:STE 813
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-9084
Practice Address - Country:US
Practice Address - Phone:713-960-1311
Practice Address - Fax:713-960-1325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5639174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty