MEDICARE: AFFILLIATED DERMATOLOGISTS OF CORPUS CHRISTI P.A.

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	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	BS#K40V	OTHER	TX	BLUE SHIELD

General Provider Information

NPI Number	:	1891828026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFILLIATED DERMATOLOGISTS OF CORPUS CHRISTI P.A.

Provider Business Mailing Address
First Line	:	4521 S STAPLES ST STE 100
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78411-2603
Country	:	US
Telephone Number	:	361-993-9363
Fax Number	:	361-993-9366

Provider Business Practice Location Address
First Line	:	4521 S STAPLES ST STE 100
Second Line	:
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78411-2603
Country	:	US
Telephone Number	:	361-993-9363
Fax Number	:	361-993-9366

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DONALD L. IDEN
Credential	:	M.D.
Telephone Number	:	361-993-9363

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	08/22/2020

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Directions to “AFFILLIATED DERMATOLOGISTS OF CORPUS CHRISTI P.A. ” Practice Location

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