Provider Demographics
NPI:1487060679
Name:PEDIATRIC DERMATOLOGY OF NO. TX
Entity type:Organization
Organization Name:PEDIATRIC DERMATOLOGY OF NO. TX
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:GHALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-421-3376
Mailing Address - Street 1:1325 W NORTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3141
Mailing Address - Country:US
Mailing Address - Phone:817-421-3376
Mailing Address - Fax:817-416-4269
Practice Address - Street 1:1325 W NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-3141
Practice Address - Country:US
Practice Address - Phone:817-421-3376
Practice Address - Fax:817-416-4269
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PEDIATRIC DERMATOLOGY OF NO. TX
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1639286339OtherTYPE 1 NPI