MEDICARE: DERMATOLOGY & CUTANEOUS SURGERY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician		TX

General Provider Information

NPI Number	:	1245540202
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY & CUTANEOUS SURGERY PLLC

Provider Business Mailing Address
First Line	:	8015 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-7018
Country	:	US
Telephone Number	:	817-453-4440
Fax Number	:	817-453-7755

Provider Business Practice Location Address
First Line	:	8015 S COOPER ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76001-7018
Country	:	US
Telephone Number	:	817-453-4440
Fax Number	:	817-453-7755

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	VICTORIA WATT SERRALTA
Credential	:	MD
Telephone Number	:	817-453-4440

Provider Enumeration Date	:	10/08/2010
Last Update Date	:	06/27/2011

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