MEDICARE: NORTHSTAR DERMATOLOGY, PA

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	:	1407176043
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHSTAR DERMATOLOGY, PA

Provider Business Mailing Address
First Line	:	8169 PRECINCT LINE RD BLDG 2
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-8607
Country	:	US
Telephone Number	:	817-427-3376
Fax Number	:	817-427-3379

Provider Business Practice Location Address
First Line	:	8169 PRECINCT LINE RD BLDG 2
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-8607
Country	:	US
Telephone Number	:	817-427-3376
Fax Number	:	817-427-3379

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AMIR ABOUTALEBI
Credential	:
Telephone Number	:	817-427-3376

Provider Enumeration Date	:	06/06/2010
Last Update Date	:	11/30/2023

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