Provider Demographics
NPI:1184410987
Name:PRODERM PLLC
Entity type:Organization
Organization Name:PRODERM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SYDNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PROFFER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-535-6000
Mailing Address - Street 1:4516 SETON CENTER PKWY
Mailing Address - Street 2:STE 150
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5370
Mailing Address - Country:US
Mailing Address - Phone:512-535-6000
Mailing Address - Fax:512-610-0262
Practice Address - Street 1:4516 SETON CENTER PKWY
Practice Address - Street 2:STE 150
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5370
Practice Address - Country:US
Practice Address - Phone:512-535-6000
Practice Address - Fax:512-610-0262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty