Provider Demographics
NPI:1568661908
Name:SOUTH TYLER DERMATOLOGY
Entity Type:Organization
Organization Name:SOUTH TYLER DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSCIAN/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANNISE
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-509-2020
Mailing Address - Street 1:5791 COPELAND RD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3905
Mailing Address - Country:US
Mailing Address - Phone:903-509-2020
Mailing Address - Fax:903-509-2355
Practice Address - Street 1:5791 COPELAND RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3905
Practice Address - Country:US
Practice Address - Phone:903-509-2020
Practice Address - Fax:903-509-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2238174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty