=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063178846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DALLAS METRO SKIN HEALTH PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2021
-----------------------------------------------------
Last Update Date | 11/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4252A OAK LAWN AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75219-2312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-253-8690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 810 WAUGH DR STE 100
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77019-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-661-6934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK D KHORSANDI
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 347-661-6934
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------