MEDICARE: DERM TEXAS LLC

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	207ND0101X	MOHS-Micrographic Surgery Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1386215002
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERM TEXAS LLC

Provider Business Mailing Address
First Line	:	2110 RESEARCH ROW STE 100C
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-2519
Country	:	US
Telephone Number	:	214-845-6426
Fax Number	:	214-845-7544

Provider Business Practice Location Address
First Line	:	2110 RESEARCH ROW STE 100C
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-2519
Country	:	US
Telephone Number	:	214-845-6426
Fax Number	:	214-845-7544

Authorized Official
Title or Position	:	MEMBER
Name	:	KELLY WARREN
Credential	:	MD
Telephone Number	:	727-221-6415

Provider Enumeration Date	:	07/03/2021
Last Update Date	:	12/06/2024

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Directions to “DERM TEXAS LLC ” Practice Location

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