Provider Demographics
NPI:1699044800
Name:BALCONES DERMATOLOGY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:BALCONES DERMATOLOGY ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUSHORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-459-4869
Mailing Address - Street 1:8240 N. MO PAC EXPWY,
Mailing Address - Street 2:STE 350
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759
Mailing Address - Country:US
Mailing Address - Phone:512-459-4869
Mailing Address - Fax:512-453-2795
Practice Address - Street 1:8240 N. MO PAC EXPWY,
Practice Address - Street 2:STE 350
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759
Practice Address - Country:US
Practice Address - Phone:512-459-4869
Practice Address - Fax:512-453-2795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-16
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6307207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH94110Medicare UPIN