Provider Demographics
NPI:1053723239
Name:LONE STAR STATE DERMATOLOGY CLINIC PLLC
Entity type:Organization
Organization Name:LONE STAR STATE DERMATOLOGY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEACOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-651-3233
Mailing Address - Street 1:11101 TOEPPERWEIN RD
Mailing Address - Street 2:
Mailing Address - City:LIVE OAK
Mailing Address - State:TX
Mailing Address - Zip Code:78233-3048
Mailing Address - Country:US
Mailing Address - Phone:210-651-3233
Mailing Address - Fax:210-651-3234
Practice Address - Street 1:11101 TOEPPERWEIN RD
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:TX
Practice Address - Zip Code:78233-3048
Practice Address - Country:US
Practice Address - Phone:210-651-3233
Practice Address - Fax:210-651-3234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-22
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8022207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H19937Medicare UPIN