Provider Demographics
NPI:1891029476
Name:WESTLAKE DERMATOLOGY, PA
Entity Type:Organization
Organization Name:WESTLAKE DERMATOLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
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 1:6836 BEE CAVES RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5059
Mailing Address - Country:US
Mailing Address - Phone:512-328-3376
Mailing Address - Fax:512-306-0222
Practice Address - Street 1:401 RR 620 N
Practice Address - Street 2:SUITE 200
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-3910
Practice Address - Country:US
Practice Address - Phone:512-610-0549
Practice Address - Fax:512-306-0222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207K00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00591TMedicare PIN