MEDICARE: ABSOLUTE DERMATOLOGY & MEDI - SPA, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	858930	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1215934195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABSOLUTE DERMATOLOGY & MEDI - SPA, PA

Provider Business Mailing Address
First Line	:	PO BOX 2166
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78297-2166
Country	:	US
Telephone Number	:	512-257-7600
Fax Number	:	512-257-7604

Provider Business Practice Location Address
First Line	:	1103 CYPRESS CREEK RD
Second Line	:	STE 100
City	:	CEDAR PARK
State	:	TX
Zip	:	78613-3925
Country	:	US
Telephone Number	:	512-257-7600
Fax Number	:	512-257-7604

Authorized Official
Title or Position	:	OWNER
Name	:	LORI F HONEYCUTT
Credential	:	MD
Telephone Number	:	512-257-7600

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/21/2022

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