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General NPI Number Information
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NPI Number | 1780765172
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Entity Type | Organization
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Legal Business Name | LAKEWAY DERMATOLOGY AND SKIN CANCER
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Dates
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Enumeration Date | 10/18/2006
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Last Update Date | 08/31/2016
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Provider Practice Location Address
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Address Line | 1313 RR 620 SOUTH SUITE 201
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City | LAKEWAY
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State | TX
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Zip | 78734-6333
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Country | US
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Telephone | 512-263-0057
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Fax | 512-263-0221
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Provider Business Mailing Address
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Address Line | 3464 RR 620 S
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City | BEE CAVE
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State | TX
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Zip | 78738-6805
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Country | US
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Telephone | 512-263-0057
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Fax | 512-263-0221
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARY ANA CUNNINGHAM
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Credential | M.D.
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Telephone | 512-263-0057
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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 | K5280
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License Number State | TX
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