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General NPI Number Information
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NPI Number | 1184410987
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Entity Type | Organization
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Legal Business Name | PRODERM PLLC
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Dates
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Enumeration Date | 04/17/2025
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Last Update Date | 06/17/2025
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Provider Practice Location Address
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Address Line | 4516 SETON CENTER PKWY STE 150
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City | AUSTIN
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State | TX
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Zip | 78759-5370
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Country | US
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Telephone | 512-535-6000
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Fax | 512-610-0262
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Provider Business Mailing Address
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Address Line | 4516 SETON CENTER PKWY STE 150
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City | AUSTIN
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State | TX
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Zip | 78759-5370
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Country | US
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Telephone | 512-535-6000
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Fax | 512-610-0262
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | SYDNEY LARKIN PROFFER
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Credential | MD
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Telephone | 512-535-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number |
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License Number State |
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