Healthcare Provider Details

I. General information

NPI: 1619942182
Provider Name (Legal Business Name): SOUTHWEST SKIN & CANCER CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 FRONTIER TRL SUITE 110
AUSTIN TX
78745-1686
US

IV. Provider business mailing address

4419 FRONTIER TRL SUITE 110
AUSTIN TX
78745-1686
US

V. Phone/Fax

Practice location:
  • Phone: 512-444-7208
  • Fax: 512-444-2343
Mailing address:
  • Phone: 512-444-7208
  • Fax: 512-444-2343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN DOUGLAS HOUSTON
Title or Position: OWNER
Credential: M.D.
Phone: 512-444-7208