Provider Demographics
NPI:1447361621
Name:CORPUS CHRISTI ALLERGY & DERMATOLOGY CLINIC PA
Entity type:Organization
Organization Name:CORPUS CHRISTI ALLERGY & DERMATOLOGY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-882-3487
Mailing Address - Street 1:PO BOX 60170
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78466
Mailing Address - Country:US
Mailing Address - Phone:361-882-3487
Mailing Address - Fax:361-882-3811
Practice Address - Street 1:5402 S STAPLES SUITE 205
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411
Practice Address - Country:US
Practice Address - Phone:361-882-3487
Practice Address - Fax:361-882-3811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3177207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1699779652OtherNPI
TX00689NMedicare ID - Type Unspecified
D79656Medicare UPIN