Provider Demographics
NPI:1811229180
Name:SKIN SURGERY CENTER, PA
Entity Type:Organization
Organization Name:SKIN SURGERY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:E
Authorized Official - Last Name:MARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-924-5200
Mailing Address - Street 1:3000 S HULEN ST
Mailing Address - Street 2:SUITE 124-228
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-1929
Mailing Address - Country:US
Mailing Address - Phone:817-924-5200
Mailing Address - Fax:817-924-5266
Practice Address - Street 1:6208 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6223
Practice Address - Country:US
Practice Address - Phone:817-924-5200
Practice Address - Fax:817-924-5266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-11
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5353207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty