Provider Demographics
NPI:1285668780
Name:PROFFITT, JOHN LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LESLIE
Last Name:PROFFITT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 OAK LAWN AVE
Mailing Address - Street 2:SUITE 650
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4308
Mailing Address - Country:US
Mailing Address - Phone:214-526-8100
Mailing Address - Fax:
Practice Address - Street 1:3500 OAK LAWN AVE
Practice Address - Street 2:SUITE 650
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4308
Practice Address - Country:US
Practice Address - Phone:214-526-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0421188207N00000X
TXG5850207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSM826954Medicare ID - Type Unspecified
KSC20708Medicare UPIN