Provider Demographics
NPI:1003327545
Name:WEST OAK DERMATOLOGY INC
Entity Type:Organization
Organization Name:WEST OAK DERMATOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:BOYSE
Authorized Official - Last Name:GANT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-755-0077
Mailing Address - Street 1:258 GIBSON DR
Mailing Address - Street 2:STE 140
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-5881
Mailing Address - Country:US
Mailing Address - Phone:916-755-0077
Mailing Address - Fax:916-755-0099
Practice Address - Street 1:258 GIBSON DR
Practice Address - Street 2:STE 140
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-5881
Practice Address - Country:US
Practice Address - Phone:916-755-0077
Practice Address - Fax:916-755-0099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-23
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123615207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty