Healthcare Provider Details

I. General information

NPI: 1417238999
Provider Name (Legal Business Name): INNOVATIVE DERMATOLOGY P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 W SPRING CREEK PKWY SUITE 265
PLANO TX
75024-4236
US

IV. Provider business mailing address

5425 W SPRING CREEK PKWY SUITE 265
PLANO TX
75024-4236
US

V. Phone/Fax

Practice location:
  • Phone: 214-919-3500
  • Fax: 214-919-3501
Mailing address:
  • Phone: 214-919-3500
  • Fax: 214-919-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN3612
License Number StateTX

VIII. Authorized Official

Name: SEEMAL R DESAI
Title or Position: OWNER
Credential: MD
Phone: 214-919-3500