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General NPI Number Information
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NPI Number | 1457465452
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Entity Type | Organization
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Legal Business Name | BRAZOSPORT DERMATOLOGY CLINIC PA
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Dates
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Enumeration Date | 08/18/2006
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Last Update Date | 12/30/2010
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Provider Practice Location Address
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Address Line | BRAZOSPORT DERMATOLOGY CLINIC PA 215 OAK DRIVE SOUTH STE C
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City | LAKE JACKSON
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State | TX
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Zip | 77566
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Country | US
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Telephone | 979-297-6458
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Fax | 979-297-0076
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Provider Business Mailing Address
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Address Line | 215 OAK DR S STE C
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5617
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Country | US
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Telephone | 979-297-6458
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Fax | 979-297-0076
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Authorized Official
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Title or Position | PRESIDENT
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Name | FRANK A PELTIER
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Credential | MD
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Telephone | 979-297-6458
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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 | F1894
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License Number State | TX
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