Provider Demographics
NPI:1619977295
Name:WYRICK DERMATOLOGY ASSOCIATION
Entity Type:Organization
Organization Name:WYRICK DERMATOLOGY ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:W
Authorized Official - Last Name:WYRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-792-3787
Mailing Address - Street 1:3333 POTOMAC AVE
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-3513
Mailing Address - Country:US
Mailing Address - Phone:903-792-3787
Mailing Address - Fax:903-792-0446
Practice Address - Street 1:3333 POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-3513
Practice Address - Country:US
Practice Address - Phone:903-792-3787
Practice Address - Fax:903-792-0446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX109371802Medicaid
AR145002002Medicaid
TX00360NMedicare ID - Type UnspecifiedPROVIDER IDENTIFICATION