Healthcare Provider Details

I. General information

NPI: 1568774735
Provider Name (Legal Business Name): SKIN SURGERY OF SAN ANTONIO, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2010
Last Update Date: 07/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2632 BROADWAY ST 201 SOUTH
SAN ANTONIO TX
78215-1137
US

IV. Provider business mailing address

2632 BROADWAY ST 201 SOUTH
SAN ANTONIO TX
78215-1137
US

V. Phone/Fax

Practice location:
  • Phone: 210-226-0040
  • Fax:
Mailing address:
  • Phone: 210-226-0040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: PAULA VOGEL
Title or Position: PRESIDENT
Credential: MD
Phone: 210-226-0040