Provider Demographics
NPI:1376575324
Name:JOHN R. WEST MD INC
Entity Type:Organization
Organization Name:JOHN R. WEST MD INC
Other - Org Name:SEAPORT DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:WEST
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:860-572-9994
Mailing Address - Street 1:34 WATER ST # 2
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2524
Mailing Address - Country:US
Mailing Address - Phone:860-572-9994
Mailing Address - Fax:860-572-9930
Practice Address - Street 1:34 WATER ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2524
Practice Address - Country:US
Practice Address - Phone:860-572-9994
Practice Address - Fax:860-572-9930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010044204CT01OtherBLUE CROSS BLUE SHIELD
CT070000518Medicare PIN
CT010044204CT01OtherBLUE CROSS BLUE SHIELD