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1225567704 NPI number — LADERA PARK DERMATOLOGY PA

NPI Number: 1225567704
Health Care Provider/Practitioner: LADERA PARK DERMATOLOGY PA

Information about “1225567704” NPI (LADERA PARK DERMATOLOGY PA) exists in 1225567704 in HTML format HTML  |  1225567704 in plain Text format TXT  |  1225567704 in PDF (Portable Document Format) PDF  |  1225567704 in an XML format XML  formats.

NPI Number : 1225567704 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1225567704",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "LADERA PARK DERMATOLOGY PA",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": "6",
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "11671 JOLLYVILLE RD STE 104",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "AUSTIN",
    "MailingAddressStateName": "TX",
    "MailingAddressPostalCode": "78759-4141",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "512-345-3599",
    "MailingAddressFaxNumber": "512-345-3928",
    "FirstLinePracticeLocationAddress": "11671 JOLLYVILLE RD STE 104",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "AUSTIN",
    "PracticeLocationAddressStateName": "TX",
    "PracticeLocationAddressPostalCode": "78759-4141",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "512-345-3599",
    "PracticeLocationAddressFaxNumber": "512-345-3928",
    "EnumerationDate": "06/08/2017",
    "LastUpdateDate": "07/21/2022",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "FEASEL",
    "AuthorizedOfficialFirstName": "ADRIENNE",
    "AuthorizedOfficialMiddleName": "M",
    "AuthorizedOfficialTitle": "PRESIDENT",
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "MD",
    "AuthorizedOfficialTelephoneNumber": "512-345-3599",
    "Taxonomies": {
      "Taxonomy": {
        "TaxonomyCode": "207N00000X",
        "TaxonomyName": "Dermatology Physician",
        "LicenseNumber": "L2883",
        "LicenseNumberStateCode": "TX",
        "PrimaryTaxonomySwitch": "Y"
      }
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193400000X SINGLE SPECIALTY  GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
      }
    }
  }
}
                
            

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