Healthcare Provider Details

I. General information

NPI: 1083769467
Provider Name (Legal Business Name): COCKERELL DERMATOLOGY CONSULTING SERVICES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 08/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 RESEARCH ROW SUITE 100
DALLAS TX
75235-2520
US

IV. Provider business mailing address

25 HIGHLAND PARK VLG BOX 100-335
DALLAS TX
75205-2789
US

V. Phone/Fax

Practice location:
  • Phone: 214-530-5200
  • Fax:
Mailing address:
  • Phone: 817-379-5381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberF9311
License Number StateTX

VIII. Authorized Official

Name: MRS. JEAN HAYWOOD
Title or Position: ACCOUNTS MANAGER
Credential:
Phone: 817-379-5381