Provider Demographics
NPI:1477668747
Name:FORT WORTH DERMATOLOGY ASSOCIATES P A
Entity type:Organization
Organization Name:FORT WORTH DERMATOLOGY ASSOCIATES P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:MABERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-336-8131
Mailing Address - Street 1:1200 W ROSEDALE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4454
Mailing Address - Country:US
Mailing Address - Phone:817-336-8131
Mailing Address - Fax:
Practice Address - Street 1:1200 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4454
Practice Address - Country:US
Practice Address - Phone:817-336-8131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC8359207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherTAX ID #
TX070009295Medicare PIN
TX=========OtherTAX ID #
TX00U62UMedicare UPIN
TXCC8286Medicare PIN
00U62UMedicare PIN