Provider Demographics
NPI:1417010935
Name:LADERA PARK DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:LADERA PARK DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:C
Authorized Official - Last Name:DUBOIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-345-3599
Mailing Address - Street 1:11671 JOLLYVILLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-4141
Mailing Address - Country:US
Mailing Address - Phone:512-345-3599
Mailing Address - Fax:512-345-3928
Practice Address - Street 1:11671 JOLLYVILLE RD STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-4141
Practice Address - Country:US
Practice Address - Phone:512-345-3599
Practice Address - Fax:512-345-3928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0001MUOtherBLUE CROSS GROUP NUMBER
TX00196ZMedicare ID - Type UnspecifiedGROUP NUMBER