Provider Demographics
NPI:1285903179
Name:SOUTH TEXAS DERMATOLOGY PLLC
Entity type:Organization
Organization Name:SOUTH TEXAS DERMATOLOGY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VINCENT
Authorized Official - Suffix:
Authorized Official - Credentials:CDC
Authorized Official - Phone:361-882-2338
Mailing Address - Street 1:1300 THIRD STREET
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78404
Mailing Address - Country:US
Mailing Address - Phone:361-882-5560
Mailing Address - Fax:361-882-6011
Practice Address - Street 1:1300 THIRD STREET
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404
Practice Address - Country:US
Practice Address - Phone:361-882-5560
Practice Address - Fax:361-882-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-21
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4105174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty