Provider Demographics
NPI:1275925869
Name:DERMATOLOGY SPECIALISTS OF SAN ANTONIO, PLLC
Entity Type:Organization
Organization Name:DERMATOLOGY SPECIALISTS OF SAN ANTONIO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-541-4884
Mailing Address - Street 1:4919 MEMORIAL HWY STE 150
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-7516
Mailing Address - Country:US
Mailing Address - Phone:813-333-1512
Mailing Address - Fax:813-333-1561
Practice Address - Street 1:2520 BROADWAY ST STE 202
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1149
Practice Address - Country:US
Practice Address - Phone:210-541-4884
Practice Address - Fax:210-541-4900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH000R0R101OtherBCBSTX