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General NPI Number Information
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NPI Number | 1073263380
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE DERMATOLOGY PLLC
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Dates
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Enumeration Date | 03/28/2022
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Last Update Date | 03/28/2022
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Provider Practice Location Address
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Address Line | 3300 S ASPEN AVE STE A
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City | BROKEN ARROW
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State | OK
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Zip | 74012-7501
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Country | US
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Telephone | 918-760-0700
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Fax |
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Provider Business Mailing Address
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Address Line | 6966 S UTICA AVE STE 225
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City | TULSA
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State | OK
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Zip | 74136-3903
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Country | US
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Telephone | 918-492-6333
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Fax | 918-493-9405
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Authorized Official
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Title or Position | OWNER
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Name | ALISON FISCHER
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Credential |
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Telephone | 918-760-0700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number |
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License Number State |
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