Provider Demographics
NPI:1598997454
Name:TEXAS DERMATOLOGY INSTITUTE
Entity Type:Organization
Organization Name:TEXAS DERMATOLOGY INSTITUTE
Other - Org Name:TEXAS INSTITUTE OF DERMATOLOGY, LASER AND COSMETIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:PROF
Authorized Official - First Name:REZA
Authorized Official - Middle Name:F
Authorized Official - Last Name:GHOHESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:210-846-5350
Mailing Address - Street 1:24165 W IH 10
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1114
Mailing Address - Country:US
Mailing Address - Phone:830-494-3376
Mailing Address - Fax:844-819-1872
Practice Address - Street 1:24165 IH 10 W
Practice Address - Street 2:SUITE 102
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1159
Practice Address - Country:US
Practice Address - Phone:888-884-5557
Practice Address - Fax:210-547-7913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-11
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0043207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty