Healthcare Provider Details

I. General information

NPI: 1710440078
Provider Name (Legal Business Name): PRISCILLA LY KOJDER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PRISCILLA FONG LY MD

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6750 N MACARTHUR BLVD STE 260
IRVING TX
75039-2489
US

IV. Provider business mailing address

9900 N CENTRAL EXPY STE 500
DALLAS TX
75231-0928
US

V. Phone/Fax

Practice location:
  • Phone: 214-987-3376
  • Fax: 214-692-6567
Mailing address:
  • Phone: 214-987-3376
  • Fax: 469-532-0273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberU8758
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberU8758
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: