Provider Demographics
NPI:1568523793
Name:WEST DERMATOLOGY OF NORTHERN CALIFORNIA, INC
Entity Type:Organization
Organization Name:WEST DERMATOLOGY OF NORTHERN CALIFORNIA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:J ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WEST
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:909-335-8649
Mailing Address - Street 1:101 E REDLANDS BLVD
Mailing Address - Street 2:SUITE 212
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4775
Mailing Address - Country:US
Mailing Address - Phone:909-335-8649
Mailing Address - Fax:909-335-1994
Practice Address - Street 1:1444 FLORIDA AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4400
Practice Address - Country:US
Practice Address - Phone:209-526-4384
Practice Address - Fax:209-526-4385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2008-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADF6859OtherRAILROAD MEDICARE
CAX05D000013Medicare PIN
CADF6859OtherRAILROAD MEDICARE