Provider Demographics
NPI:1457465452
Name:BRAZOSPORT DERMATOLOGY CLINIC PA
Entity Type:Organization
Organization Name:BRAZOSPORT DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:A
Authorized Official - Last Name:PELTIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:979-297-6458
Mailing Address - Street 1:215 OAK DR S
Mailing Address - Street 2:STE C
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566-5617
Mailing Address - Country:US
Mailing Address - Phone:979-297-6458
Mailing Address - Fax:979-297-0076
Practice Address - Street 1:BRAZOSPORT DERMATOLOGY CLINIC PA
Practice Address - Street 2:215 OAK DRIVE SOUTH STE C
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566
Practice Address - Country:US
Practice Address - Phone:979-297-6458
Practice Address - Fax:979-297-0076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1894207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX035781601Medicaid
B25455Medicare UPIN
TX035781601Medicaid