Provider Demographics
NPI:1477678993
Name:WESTLAKE DERMATOLOGY PA
Entity Type:Organization
Organization Name:WESTLAKE DERMATOLOGY PA
Other - Org Name:WESTLAKE DERMATOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKOLAIDIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-328-3376
Mailing Address - Street 1:8825 BEE CAVE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-4719
Mailing Address - Country:US
Mailing Address - Phone:512-328-3376
Mailing Address - Fax:512-306-0222
Practice Address - Street 1:1760 ROUND ROCK AVE
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4217
Practice Address - Country:US
Practice Address - Phone:512-583-3376
Practice Address - Fax:512-306-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00591TOtherBCBS OF TEXAS GROUP#
TX211724401Medicaid
TX00591TOtherBCBS OF TEXAS GROUP#