Provider Demographics
NPI:1912418963
Name:SUMMIT DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:SUMMIT DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLASER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-593-9474
Mailing Address - Street 1:1038 S FLEISHEL AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2044
Mailing Address - Country:US
Mailing Address - Phone:903-593-9474
Mailing Address - Fax:903-593-9477
Practice Address - Street 1:1038 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2044
Practice Address - Country:US
Practice Address - Phone:903-593-9474
Practice Address - Fax:903-593-9477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK9734207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty