Provider Demographics
NPI:1821240995
Name:WESTGATE DERMATOLOGY AND LASER CENTER, P.A.
Entity Type:Organization
Organization Name:WESTGATE DERMATOLOGY AND LASER CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOSTUCHENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-768-1280
Mailing Address - Street 1:2020 PEACE HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-4851
Mailing Address - Country:US
Mailing Address - Phone:336-768-1280
Mailing Address - Fax:
Practice Address - Street 1:2020 PEACE HAVEN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-4851
Practice Address - Country:US
Practice Address - Phone:336-768-1280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-21
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQPB766OtherSC MEDICAID
SCQPB766Medicaid
NC5950698Medicaid
NC2026585BMedicare PIN