Lone Star State Dermatology Clinic PLLC

Primary specialty

Procedural Dermatology PhysicianTaxonomy code 207NS0135X

License

K8022 Issued in TX

Legal business name

LONE STAR STATE DERMATOLOGY CLINIC PLLC

Practice address

11101 Toepperwein Rd
Live Oak, TX 78233-3048

Phone

(210) 651-3233

Fax

(210) 651-3234

NPI assigned

May 22, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Myra Peacock

Title

Office Manager

Phone

(210) 651-3233

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in TX

Enrollment records 1

Locations

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Jean-Denis Boucher, M.D.

  • Procedural Dermatology Physician
  • Live Oak, TX
  • NPI 1205827532
  Medicare reassignment Care Compare group NPD
• Derek Felix Deleon, APRN

  • Acute Care Nurse Practitioner
  • San Antonio, TX
  • NPI 1609514785
  Medicare reassignment Care Compare group NPD
• Baolong Viet Nguyen, PA-C

  • Physician Assistant
  • San Antonio, TX
  • NPI 1124795299
  Medicare reassignment
• Amanda Palmer

  • Physician Assistant
  • New Braunfels, TX
  • NPI 1467018895
  Medicare reassignment
• Ruby Mae Balderas, PA-C

  • Physician Assistant
  • McAllen, TX
  • NPI 1780992339
  NPD (past)
• Brianna Kay, PA-C

  • Physician Assistant
  • New Braunfels, TX
  • NPI 1356784243
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1400716800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1703030400000",
    "number": "1053723239",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11101 TOEPPERWEIN RD",
            "city": "LIVE OAK",
            "state": "TX",
            "postal_code": "782333048",
            "telephone_number": "210-651-3233",
            "fax_number": "210-651-3234"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11101 TOEPPERWEIN RD",
            "city": "LIVE OAK",
            "state": "TX",
            "postal_code": "782333048",
            "telephone_number": "210-651-3233",
            "fax_number": "210-651-3234"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LONE STAR STATE DERMATOLOGY CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-05-22",
        "last_updated": "2023-12-20",
        "certification_date": "2023-12-20",
        "status": "A",
        "authorized_official_last_name": "PEACOCK",
        "authorized_official_first_name": "MYRA",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "210-651-3233"
    },
    "taxonomies": [
        {
            "code": "207NS0135X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology, Procedural Dermatology",
            "state": "TX",
            "license": "K8022",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Live Oak Allergy & Asthma Clinic; PA
• Live Oak Pediatric Dentistry
• Live Oak Pediatrics, PA
• Kenneth Omer Livingston Jr., D.D.S.
• Samantha Ann Logue, MSN, APRN, FNP-C
• Elizabeth Kay Long, FNP
• Joao Lopes, PT
• Deryck Bryan Lopez Garcia, DPT
• Gracie Ann Lopez
• Jorge Luis Lopez

• Procedural Dermatology Physician in Live Oak, TX
• Providers in Live Oak, TX by specialty
• Procedural Dermatology Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 20, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.