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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