Provider Demographics
NPI:1528271624
Name:SOUTHWEST COSMETIC DERMATOLOGY ASSOCIATES
Entity type:Organization
Organization Name:SOUTHWEST COSMETIC DERMATOLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RICHMOND
Authorized Official - Last Name:MCCARTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-920-9023
Mailing Address - Street 1:4365 S HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4917
Mailing Address - Country:US
Mailing Address - Phone:817-920-9023
Mailing Address - Fax:817-923-6013
Practice Address - Street 1:4365 S HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4917
Practice Address - Country:US
Practice Address - Phone:817-920-9023
Practice Address - Fax:817-923-6013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2711174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC19044Medicare UPIN
TX00U18BMedicare ID - Type Unspecified