NPIMap

Organization Active NPI

Prestige Dermatology of Alliance, PLLC

  • Dermatology Physician
  • Fort Worth, TX
National Provider Identifier
1427415314
Registry record updated Jan 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
PRESTIGE DERMATOLOGY OF ALLIANCE, PLLC
Practice address
3629 Western Center Blvd
Suite 201
Fort Worth, TX 76137-1939
Phone
(817) 766-7421
NPI assigned
Jan 22, 2016
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 21, 2021

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

Authorized official

Name
Ryan Pham, D.ONPI 1407173230
Title
Managing Member
Phone
(817) 766-7421

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207N00000X Primary
Family Medicine PhysicianGroup: 193400000X MULTIPLE SINGLE SPECIALTY GROUP 207Q00000X

Addresses

Primary practice location

3629 Western Center Blvd
Suite 201
Fort Worth, TX 76137-1939

Mailing address

3629 Western Center Blvd Ste 211
Fort Worth, TX 76137-1940
Phone (817) 766-7422

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20160307000266 TX Part B Supplier - Clinic/Group Practice 4284930959 Receives reassigned benefits from 9 practitioners
Practice locations: Fort Worth, TX

National Provider Directory

National Provider Directory

Locations

621 SW Johnson Ave
Ste C
Burleson, TX 76028
Phone (817) 718-3571

3629 Western Center Blvd
Ste 221
Fort Worth, TX 76137
Phone (817) 232-9115

3629 Western Center Blvd
Ste 201
Ft Worth, TX 76137
Phone (817) 232-9870

Practitioners & affiliated clinicians

Practitioners 9

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

NPI Registry JSON

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

{
    "created_epoch": "1453420800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1611187200000",
    "number": "1427415314",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3629 WESTERN CENTER BLVD STE 211",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761371940",
            "telephone_number": "817-766-7422"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3629 WESTERN CENTER BLVD",
            "address_2": "SUITE 201",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761371939",
            "telephone_number": "817-766-7421"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRESTIGE DERMATOLOGY OF ALLIANCE, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-22",
        "last_updated": "2021-01-21",
        "certification_date": "2021-01-21",
        "status": "A",
        "authorized_official_last_name": "PHAM",
        "authorized_official_first_name": "RYAN",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "817-766-7421",
        "authorized_official_credential": "D.O"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Worth, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 21, 2021; 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.