Healthcare Provider Details

I. General information

NPI: 1568753747
Provider Name (Legal Business Name): INTEGRATED DERMATOLOGY CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5061 FM 2920
SPRING TX
77388
US

IV. Provider business mailing address

5061 FM 2920
SPRING TX
77388
US

V. Phone/Fax

Practice location:
  • Phone: 281-829-8288
  • Fax: 281-404-9336
Mailing address:
  • Phone: 281-829-8288
  • Fax: 281-404-9336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberN2439
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberN2439
License Number StateTX

VIII. Authorized Official

Name: DR. MELISSA PHYLLIS CHIANG
Title or Position: MD
Credential: MD
Phone: 281-829-8288