Healthcare Provider Details

I. General information

NPI: 1922244771
Provider Name (Legal Business Name): SKIN SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date: 10/12/2020
Reactivation Date: 11/24/2020

III. Provider practice location address

1101 RAINTREE CIR 250
ALLEN TX
75013-4922
US

IV. Provider business mailing address

1101 RAINTREE CIR 250
ALLEN TX
75013-4922
US

V. Phone/Fax

Practice location:
  • Phone: 972-649-6644
  • Fax: 972-649-6663
Mailing address:
  • Phone: 972-649-6644
  • Fax: 972-649-6663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN1109
License Number StateTX

VIII. Authorized Official

Name: TANYA REDDICK RODGERS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 972-649-6644