Provider Demographics
NPI:1568515047
Name:DERMATOLOGY AND LASER CENTER OF TYLER, P.A.
Entity Type:Organization
Organization Name:DERMATOLOGY AND LASER CENTER OF TYLER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:S
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-595-2737
Mailing Address - Street 1:700 OLYMPIC PLAZA CIR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1951
Mailing Address - Country:US
Mailing Address - Phone:903-595-2737
Mailing Address - Fax:903-592-2732
Practice Address - Street 1:700 OLYMPIC PLAZA CIR
Practice Address - Street 2:SUITE 404
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-1951
Practice Address - Country:US
Practice Address - Phone:903-595-2737
Practice Address - Fax:903-592-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0686174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXA87994Medicare UPIN