Healthcare Provider Details

I. General information

NPI: 1003350760
Provider Name (Legal Business Name): WARTHAN DERMATOLOGY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 12/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 NE STALLINGS DR
NACOGDOCHES TX
75965-1615
US

IV. Provider business mailing address

4730 NE STALLINGS DR
NACOGDOCHES TX
75965-1615
US

V. Phone/Fax

Practice location:
  • Phone: 936-564-6107
  • Fax: 936-564-5124
Mailing address:
  • Phone: 936-564-6107
  • Fax: 936-564-5124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD8472
License Number StateTX

VIII. Authorized Official

Name: JACLYN R HILL
Title or Position: BILLING
Credential:
Phone: 817-923-8220