Provider Demographics
NPI:1447432133
Name:DERMATOLOGY PLACE PA
Entity type:Organization
Organization Name:DERMATOLOGY PLACE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUDLEY
Authorized Official - Middle Name:WINSLOW
Authorized Official - Last Name:GOETZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:817-261-9665
Mailing Address - Street 1:1000 W RANDOL MILL ROAD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2512
Mailing Address - Country:US
Mailing Address - Phone:817-261-9665
Mailing Address - Fax:817-795-5750
Practice Address - Street 1:1000 W RANDOL MILL ROAD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2512
Practice Address - Country:US
Practice Address - Phone:817-261-9665
Practice Address - Fax:817-795-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1907207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00H55NOtherGROUP ID NUMBER