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General NPI Number Information
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NPI Number | 1699120048
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Entity Type | Organization
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Legal Business Name | PALO DURO DERMATOLOGY, PLLC
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Dates
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Enumeration Date | 05/03/2016
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Last Update Date | 10/02/2016
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Provider Practice Location Address
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Address Line | 2005 N 2ND AVE STE D
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City | CANYON
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State | TX
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Zip | 79015-2545
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Country | US
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Telephone | 806-553-0185
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Fax | 806-853-6630
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Provider Business Mailing Address
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Address Line | PO BOX 1638
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City | CANYON
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State | TX
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Zip | 79015-1638
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Country | US
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Telephone | 806-488-2176
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LARRY C ROBERTS
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Credential | MD
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Telephone | 806-553-0185
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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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