MEDICARE: LADERA PARK DERMATOLOGY 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	L2883	TX

General Provider Information

NPI Number	:	1225567704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LADERA PARK DERMATOLOGY PA

Provider Business Mailing Address
First Line	:	11671 JOLLYVILLE RD STE 104
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4141
Country	:	US
Telephone Number	:	512-345-3599
Fax Number	:	512-345-3928

Provider Business Practice Location Address
First Line	:	11671 JOLLYVILLE RD STE 104
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78759-4141
Country	:	US
Telephone Number	:	512-345-3599
Fax Number	:	512-345-3928

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ADRIENNE M FEASEL
Credential	:	MD
Telephone Number	:	512-345-3599

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	07/21/2022

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