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General NPI Number Information
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NPI Number | 1417010935
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Entity Type | Organization
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Legal Business Name | LADERA PARK DERMATOLOGY, P.A.
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 02/27/2013
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Provider Practice Location Address
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Address Line | 11671 JOLLYVILLE RD STE 104
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City | AUSTIN
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State | TX
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Zip | 78759-4141
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Country | US
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Telephone | 512-345-3599
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Fax | 512-345-3928
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Provider Business Mailing Address
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Address Line | 11671 JOLLYVILLE RD STE 104
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City | AUSTIN
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State | TX
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Zip | 78759-4141
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Country | US
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Telephone | 512-345-3599
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Fax | 512-345-3928
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Authorized Official
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Title or Position | PRESIDENT
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Name | JANET C DUBOIS
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Credential | MD
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Telephone | 512-345-3599
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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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