NPIMap

Organization Active NPI

Prestige Dermatology PLLC

  • Dermatology Physician
  • Burleson, TX
National Provider Identifier
1962878843
Registry record updated May 6, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
Legal business name
PRESTIGE DERMATOLOGY PLLC
Practice address
264 Exchange St
Burleson, TX 76028-4575
Phone
(817) 766-7421
Fax
(817) 447-8100
NPI assigned
Aug 14, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 6, 2024

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

Authorized official

Name
Ryan Pham, D.O.NPI 1407173230
Title
Managing Partner
Phone
(817) 718-3571

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 1

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

Addresses

Primary practice location

264 Exchange St
Burleson, TX 76028-4575

Mailing address

621 SW Johnson Ave
Suite C
Burleson, TX 76028-5833
Phone (817) 766-7421

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20151112001450 TX Part B Supplier - Clinic/Group Practice 2365752813 Receives reassigned benefits from 10 practitioners
Practice locations: Burleson, TX

National Provider Directory

National Provider Directory

Locations

264 Exchange St
Burleson, TX 76028
Phone (817) 718-3571

3629 Western Center Blvd
Ste 211
Fort Worth, TX 76137
Phone (817) 232-9400

Interoperability endpoints

  • FHIR API: https://fhir4.healow.com/fhir/r4/HECDAD

Practitioners & affiliated clinicians

Practitioners 12

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": "1439510400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1714953600000",
    "number": "1962878843",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "621 SW JOHNSON AVE",
            "address_2": "SUITE C",
            "city": "BURLESON",
            "state": "TX",
            "postal_code": "760285833",
            "telephone_number": "817-766-7421",
            "fax_number": "817-447-8100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "264 EXCHANGE ST",
            "city": "BURLESON",
            "state": "TX",
            "postal_code": "760284575",
            "telephone_number": "817-766-7421",
            "fax_number": "817-447-8100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRESTIGE DERMATOLOGY PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-08-14",
        "last_updated": "2024-05-06",
        "certification_date": "2024-05-06",
        "status": "A",
        "authorized_official_last_name": "PHAM",
        "authorized_official_first_name": "RYAN",
        "authorized_official_title_or_position": "MANAGING PARTNER",
        "authorized_official_telephone_number": "817-718-3571",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Burleson, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 6, 2024; 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.