Healthcare Provider Details

I. General information

NPI: 1942620554
Provider Name (Legal Business Name): WEST TEXAS DERMATOLOGY AND SKIN CANCER CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3162 APPALOOSA CIR
SAN ANGELO TX
76901-5225
US

IV. Provider business mailing address

PO BOX 62701
SAN ANGELO TX
76906-2701
US

V. Phone/Fax

Practice location:
  • Phone: 325-224-5981
  • Fax: 325-224-5986
Mailing address:
  • Phone: 325-224-5981
  • Fax: 325-224-5986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: MARK ADAM RAMIREZ
Title or Position: PRESIDENT
Credential: MD
Phone: 325-224-5981