Basic Information
| Provider Information | |||||||||
| NPI: | 1487060679 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PEDIATRIC DERMATOLOGY OF NO. TX | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FRED E GHALI, MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1325 W NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174213376 | ||||||||
| FaxNumber: | 8174164269 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 W NORTHWEST HWY | ||||||||
| Address2: | |||||||||
| City: | GRAPEVINE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760513141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8174213376 | ||||||||
| FaxNumber: | 8174164269 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2014 | ||||||||
| LastUpdateDate: | 07/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | GHALI | ||||||||
| AuthorizedOfficialFirstName: | FRED | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8174213376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PEDIATRIC DERMATOLOGY OF NO. TX | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NP0225X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1639286339 | 01 | TX | TYPE 1 NPI | OTHER |