Provider Demographics
NPI:1780045260
Name:LAKEWOOD DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:LAKEWOOD DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:MCDONOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-463-8328
Mailing Address - Street 1:6162 E MOCKINGBIRD LN
Mailing Address - Street 2:STE. 120
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-2697
Mailing Address - Country:US
Mailing Address - Phone:214-463-8328
Mailing Address - Fax:
Practice Address - Street 1:6162 E MOCKINGBIRD LN
Practice Address - Street 2:STE. 120
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-2697
Practice Address - Country:US
Practice Address - Phone:214-463-8328
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-11
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6655207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX530036Medicare PIN