Provider Demographics
NPI:1386009124
Name:AMERICAN DERMATOLOGY CENTER LLC
Entity Type:Organization
Organization Name:AMERICAN DERMATOLOGY CENTER LLC
Other - Org Name:AMERICAN DERMATOLOGY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:P
Authorized Official - Last Name:NIKKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-533-0909
Mailing Address - Street 1:27150 HIGHWAY 290 STE 100
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433-4930
Mailing Address - Country:US
Mailing Address - Phone:832-533-0909
Mailing Address - Fax:832-640-7604
Practice Address - Street 1:27150 HIGHWAY 290 STE 100
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-4930
Practice Address - Country:US
Practice Address - Phone:832-533-0909
Practice Address - Fax:832-640-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5639174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1962649491OtherINDIVIDUAL NPI