Provider Demographics
NPI:1710917521
Name:ADVANCED DERMATOLOGY AND SKIN CARE PA
Entity Type:Organization
Organization Name:ADVANCED DERMATOLOGY AND SKIN CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-392-3803
Mailing Address - Street 1:PO BOX 710270
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77271-0270
Mailing Address - Country:US
Mailing Address - Phone:281-392-3803
Mailing Address - Fax:
Practice Address - Street 1:430 S MASON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-2447
Practice Address - Country:US
Practice Address - Phone:281-392-3803
Practice Address - Fax:281-392-6766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0042KKOtherBCBS
45D1019065OtherCLIA NUMBER
DD9883OtherRR MEDICARE GRP BRAZORIA
TX45D2052501OtherCLIA
DA6818OtherRR MEDICARE GRP HARRIS CO
45D1019065OtherCLIA NUMBER
TX00X105Medicare PIN
TX00482VMedicare PIN