Provider Demographics
NPI:1457532442
Name:ST. MATTHEW DERMATOLOGY CLINIC, P.A.
Entity Type:Organization
Organization Name:ST. MATTHEW DERMATOLOGY CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENATO
Authorized Official - Middle Name:MARQUEZ
Authorized Official - Last Name:ORACION
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:432-582-0370
Mailing Address - Street 1:808 TOWER DR STE 3
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4256
Mailing Address - Country:US
Mailing Address - Phone:432-582-0370
Mailing Address - Fax:
Practice Address - Street 1:808 TOWER DR STE 3
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4256
Practice Address - Country:US
Practice Address - Phone:432-582-0370
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-18
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4085207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0099KKOtherBLUE CROSS BLUE SHIELD
TXDB7529OtherRAILROAD MEDICARE
TX=========OtherTRICARE
TX=========OtherTDEF
TX=========OtherTDEF