Healthcare Provider Details

I. General information

NPI: 1144820135
Provider Name (Legal Business Name): WARTHAN DERMATOLOGY NACOGDOCHES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
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: 817-923-8220
  • Fax: 817-923-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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