Provider Demographics
NPI:1720097181
Name:TEXARKANA DERMATOLOGY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:TEXARKANA DERMATOLOGY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PARHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-223-9911
Mailing Address - Street 1:3502 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-0705
Mailing Address - Country:US
Mailing Address - Phone:903-223-9911
Mailing Address - Fax:
Practice Address - Street 1:3502 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0705
Practice Address - Country:US
Practice Address - Phone:903-223-9911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2257207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00206UMedicare PIN