Provider Demographics
NPI:1962681304
Name:ABILENE DERMATOLOGY AND SKIN SURGERY CENTER PC
Entity Type:Organization
Organization Name:ABILENE DERMATOLOGY AND SKIN SURGERY CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABOUTALEBI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:325-672-5603
Mailing Address - Street 1:3190 ANTILLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-5015
Mailing Address - Country:US
Mailing Address - Phone:325-672-5603
Mailing Address - Fax:325-672-6570
Practice Address - Street 1:3190 ANTILLEY RD
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-5006
Practice Address - Country:US
Practice Address - Phone:325-672-5603
Practice Address - Fax:325-672-6570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0087QHOtherBLUE CROSS BLUE SHIELD OF TEXAS
TXCG5724OtherRAILROAD MEDICARE
TX00Y705Medicare PIN