Provider Demographics
NPI:1164919502
Name:CENTER FOR DERMATOLOGY
Entity Type:Organization
Organization Name:CENTER FOR DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-718-3571
Mailing Address - Street 1:1100 ORCHARD DR STE B
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2519
Mailing Address - Country:US
Mailing Address - Phone:682-712-0100
Mailing Address - Fax:
Practice Address - Street 1:1100 ORCHARD DR STE B
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012
Practice Address - Country:US
Practice Address - Phone:682-712-0100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-20
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty