Healthcare Provider Details

I. General information

NPI: 1164566246
Provider Name (Legal Business Name): CENTRAL TEXAS DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 WESTLAKE DR #100
WEST LAKE HILLS TX
78746
US

IV. Provider business mailing address

102 WESTLAKE DR STE 100
WEST LAKE HILLS TX
78746-5373
US

V. Phone/Fax

Practice location:
  • Phone: 512-327-7779
  • Fax:
Mailing address:
  • Phone: 512-327-7779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberF4405
License Number StateTX

VIII. Authorized Official

Name: MRS. DEBRA PETRIE
Title or Position: BILLER/CREDENTIALER
Credential: BILLER
Phone: 512-327-8449