Organization
SOUTH TEXAS DERMATOLOGY PLLC
Active
Organization
SOUTH TEXAS DERMATOLOGY PLLC
Active
Other names
South Texas Dermatology
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER LYNN VINCENT CDC (PRQACTICE MANAGER)
(361) 882-5560
Entity
Organization
Contact information
Practice address
4141 S. STAPLES SUITE 300, CORPUS CHRISTI, TX 78411-2929
(361) 882-5560
(361) 882-6011
Mailing address
4141 S. STAPLES SUITE 300, CORPUS CHRISTI, TX 78411-2929
(361) 882-5560
(361) 882-6011
Taxonomy
Speciality
Code
Description
License number
State
207ND0101X
MOHS-Micrographic Surgery Physician
Primary
J4105
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0040EE
BLUE CROSS BLUE SHIELD
TX
05
—
080856001
—
TX
01
—
CK7292
MEDICARE RAILROAD
TX
05
—
TXB158324
—
TX
Enumeration date
09/12/2007
Last updated
07/14/2022
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