Basic Information
| Provider Information | |||||||||
| NPI: | 1073263380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHSIDE DERMATOLOGY PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6966 S UTICA AVE STE 225 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184926333 | ||||||||
| FaxNumber: | 9184939405 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 S ASPEN AVE STE A | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740127501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187600700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2022 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | FISCHER | ||||||||
| AuthorizedOfficialFirstName: | ALISON | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9187600700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.