Provider Demographics
NPI:1356536494
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:PRQACTICE MANAGER
Authorized Official - Prefix:
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:361-882-5560
Mailing Address - Street 1:4141 S. STAPLES SUITE 300
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2929
Mailing Address - Country:US
Mailing Address - Phone:361-882-5560
Mailing Address - Fax:361-882-6011
Practice Address - Street 1:4141 S. STAPLES SUITE 300
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2929
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:2007-09-12
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4105207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXCK7292OtherMEDICARE RAILROAD
TXTXB158324Medicaid
TX0040EEOtherBLUE CROSS BLUE SHIELD
TX080856001Medicaid