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General NPI Number Information
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NPI Number | 1356536494
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Entity Type | Organization
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Legal Business Name | SOUTH TEXAS DERMATOLOGY PLLC
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Dates
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Enumeration Date | 09/12/2007
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Last Update Date | 07/14/2022
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Provider Practice Location Address
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Address Line | 4141 S. STAPLES SUITE 300
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City | CORPUS CHRISTI
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State | TX
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Zip | 78411-2929
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Country | US
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Telephone | 361-882-5560
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Fax | 361-882-6011
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Provider Business Mailing Address
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Address Line | 4141 S. STAPLES SUITE 300
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City | CORPUS CHRISTI
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State | TX
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Zip | 78411-2929
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Country | US
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Telephone | 361-882-5560
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Fax | 361-882-6011
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Authorized Official
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Title or Position | PRQACTICE MANAGER
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Name | JENNIFER LYNN VINCENT
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Credential | CDC
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Telephone | 361-882-5560
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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 | J4105
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License Number State | TX
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