Healthcare Provider Details

I. General information

NPI: 1124484456
Provider Name (Legal Business Name): TEXAS SURGICAL DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2015
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21009 KUYKENDAHL SUITE A
SPRING TX
77379-0000
US

IV. Provider business mailing address

11604 WATERCASTLE CT
PEARLAND TX
77584-8210
US

V. Phone/Fax

Practice location:
  • Phone: 832-643-8592
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: TRI NGUYEN
Title or Position: MD
Credential:
Phone: 832-643-8592