Provider Demographics
NPI:1912549833
Name:PRESTIGE DERMATOLOGY OF MIDLOTHIAN
Entity Type:Organization
Organization Name:PRESTIGE DERMATOLOGY OF MIDLOTHIAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-718-3571
Mailing Address - Street 1:320 HAWKINS RUN RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065
Mailing Address - Country:US
Mailing Address - Phone:469-758-4800
Mailing Address - Fax:972-775-4567
Practice Address - Street 1:320 HAWKINS RUN RD.
Practice Address - Street 2:SUITE 1
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065
Practice Address - Country:US
Practice Address - Phone:469-758-4800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-11
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty