Provider Demographics
NPI:1396945234
Name:WALLIS DERMATOLOGY ASSOCIATES PLLC
Entity type:Organization
Organization Name:WALLIS DERMATOLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TAMRON
Authorized Official - Middle Name:G
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-757-3882
Mailing Address - Street 1:3535 N FOURTH ST STE 400
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-0038
Mailing Address - Country:US
Mailing Address - Phone:903-757-3881
Mailing Address - Fax:903-757-5948
Practice Address - Street 1:3535 N FOURTH ST STE 400
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-0038
Practice Address - Country:US
Practice Address - Phone:903-757-3881
Practice Address - Fax:903-757-5948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6685207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX302333501Medicaid
TXTXB145668Medicare PIN