MEDICARE: ABBOTT DERMATOLOGY P C

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	207NS0135X	Procedural Dermatology Physician	17800	OK
2	207ND0101X	MOHS-Micrographic Surgery Physician	17800	OK
3	207N00000X	Dermatology Physician	17800	OK
4	207ND0900X	Dermatopathology Physician	17800	OK

General Provider Information

NPI Number	:	1982658167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABBOTT DERMATOLOGY P C

Provider Business Mailing Address
First Line	:	3500 S WESTERN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-2413
Country	:	US
Telephone Number	:	405-632-5565
Fax Number	:	405-632-3538

Provider Business Practice Location Address
First Line	:	3500 S WESTERN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-2413
Country	:	US
Telephone Number	:	405-632-5565
Fax Number	:	405-632-3538

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. CRAIG LEON ABBOTT
Credential	:	M.D.
Telephone Number	:	405-632-5565

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	07/18/2007

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