Provider Demographics
NPI:1891828026
Name:AFFILLIATED DERMATOLOGISTS OF CORPUS CHRISTI P.A.
Entity Type:Organization
Organization Name:AFFILLIATED DERMATOLOGISTS OF CORPUS CHRISTI P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:IDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-993-9363
Mailing Address - Street 1:4521 S STAPLES ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2603
Mailing Address - Country:US
Mailing Address - Phone:361-993-9363
Mailing Address - Fax:361-993-9366
Practice Address - Street 1:4521 S STAPLES ST STE 100
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2603
Practice Address - Country:US
Practice Address - Phone:361-993-9363
Practice Address - Fax:361-993-9366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBS#K40VOtherBLUE SHIELD
TXB23684Medicare UPIN