Provider Demographics
NPI:1982658167
Name:ABBOTT DERMATOLOGY P C
Entity Type:Organization
Organization Name:ABBOTT DERMATOLOGY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:ABBOTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-632-5565
Mailing Address - Street 1:3500 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73109-2413
Mailing Address - Country:US
Mailing Address - Phone:405-632-5565
Mailing Address - Fax:405-632-3538
Practice Address - Street 1:3500 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-2413
Practice Address - Country:US
Practice Address - Phone:405-632-5565
Practice Address - Fax:405-632-3538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17800207N00000X, 207ND0101X, 207ND0900X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty