Provider Demographics
NPI:1235357666
Name:NORTHEAST TARRANT DERMATOLOGY, INC
Entity Type:Organization
Organization Name:NORTHEAST TARRANT DERMATOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THO
Authorized Official - Middle Name:Q
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-281-7546
Mailing Address - Street 1:1733 PRECINCT LINE ROAD
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3131
Mailing Address - Country:US
Mailing Address - Phone:817-281-7546
Mailing Address - Fax:817-788-0115
Practice Address - Street 1:1733 PRECINCT LINE RD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3131
Practice Address - Country:US
Practice Address - Phone:817-281-7546
Practice Address - Fax:817-788-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
F18814Medicare UPIN
00403TMedicare ID - Type Unspecified