Basic Information
| Provider Information | |||||||||
| NPI: | 1982658167 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABBOTT DERMATOLOGY P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731092413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056325565 | ||||||||
| FaxNumber: | 4056323538 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731092413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056325565 | ||||||||
| FaxNumber: | 4056323538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 07/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | ABBOTT | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | LEON | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4056325565 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NS0135X | 17800 | OK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207ND0101X | 17800 | OK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207N00000X | 17800 | OK | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | 17800 | OK | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology |
No ID Information.