Provider Demographics
NPI:1396862280
Name:WESTSIDE DERMATOLOGY, PLLC
Entity Type:Organization
Organization Name:WESTSIDE DERMATOLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-937-8954
Mailing Address - Street 1:4740 44TH AVE SW
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-4402
Mailing Address - Country:US
Mailing Address - Phone:206-937-8954
Mailing Address - Fax:206-937-1916
Practice Address - Street 1:4740 44TH AVE SW
Practice Address - Street 2:SUITE 200
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4402
Practice Address - Country:US
Practice Address - Phone:206-937-8954
Practice Address - Fax:206-937-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602335909207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB40330Medicare PIN