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General NPI Number Information
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NPI Number | 1811229180
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Entity Type | Organization
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Legal Business Name | SKIN SURGERY CENTER, PA
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Dates
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Enumeration Date | 02/11/2010
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Last Update Date | 02/11/2010
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Provider Practice Location Address
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Address Line | 6208 COLLEYVILLE BLVD SUITE 100
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City | COLLEYVILLE
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State | TX
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Zip | 76034-6223
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Country | US
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Telephone | 817-924-5200
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Fax | 817-924-5266
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Provider Business Mailing Address
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Address Line | 3000 S HULEN ST SUITE 124-228
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City | FORT WORTH
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State | TX
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Zip | 76109-1929
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Country | US
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Telephone | 817-924-5200
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Fax | 817-924-5266
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. DIEGO E. MARRA
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Credential | M.D.
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Telephone | 817-924-5200
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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 | M5353
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License Number State | TX
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