Provider Demographics
NPI:1346446051
Name:KATY DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:KATY DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:CZELUSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-599-0404
Mailing Address - Street 1:21310 PROVINCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-7580
Mailing Address - Country:US
Mailing Address - Phone:281-599-0404
Mailing Address - Fax:281-599-1655
Practice Address - Street 1:21310 PROVINCIAL BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-7580
Practice Address - Country:US
Practice Address - Phone:281-599-0404
Practice Address - Fax:281-599-1655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5711174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4516713OtherCIGNA
TX168278301Medicaid
TX0074LMOtherBCBS
TX00927WMedicare ID - Type Unspecified
TX4516713OtherCIGNA