Provider Demographics
| NPI: | 1932154788 |
|---|---|
| Name: | J ROBERT WEST, M.D., INC |
| Entity Type: | Organization |
| Organization Name: | J ROBERT WEST, M.D., INC |
| Other - Org Name: | SOUTHERN CALIFORNIA DERMATOLOGY |
| Other - Org Type: | Doing Business As |
| Authorized Official - Title/Position: | OWNER/PHYSICIAN |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | LUCIUS |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | BLANCHARD |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 702-360-2763 |
| Mailing Address - Street 1: | 12700 PARK CENTRAL DR STE 1210 |
| Mailing Address - Street 2: | |
| Mailing Address - City: | DALLAS |
| Mailing Address - State: | TX |
| Mailing Address - Zip Code: | 75251-1522 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 702-360-2763 |
| Mailing Address - Fax: | 949-783-2880 |
| Practice Address - Street 1: | 12700 PARK CENTRAL DR STE 1210 |
| Practice Address - Street 2: | |
| Practice Address - City: | DALLAS |
| Practice Address - State: | TX |
| Practice Address - Zip Code: | 75251-1522 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 702-360-2763 |
| Practice Address - Fax: | 949-783-2880 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | Yes |
| Parent Organization LBN: | J ROBERT WEST, M.D., INC |
| Parent Organization TIN: | <UNAVAIL> |
| Enumeration Date: | 2006-05-23 |
| Last Update Date: | 2024-03-26 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207N00000X, 332900000X | ||
| CA | G4302 | 207NS0135X, 207ZD0900X |
| CA | C53342 | 207NS0135X, 207ZD0900X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207NS0135X | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | Group - Multi-Specialty |
| No | 207N00000X | Allopathic & Osteopathic Physicians | Dermatology | Group - Multi-Specialty | |
| No | 207ZD0900X | Allopathic & Osteopathic Physicians | Pathology | Dermatopathology | Group - Multi-Specialty |
| No | 332900000X | Suppliers | Non-Pharmacy Dispensing Site | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| NV | CG5410 | Other | RAILROAD MEDICARE |
| CA | ZZZ24828Z | Other | BLUE SHIELD PROVIDER NUMB |
| CA | ZZZ24833Z | Other | BLUE SHIELD PROVIDER NUMB |
| CA | CA7620 | Other | RAILROAD MEDICARE |
| CA | CD5363 | Other | RAILROAD MEDICARE |
| CA | ZZZ24828Z | Other | BLUE SHIELD PROVIDER NUMB |
| ID | DP3341 | Other | RAILROAD MEDICARE 08/01/09 |
| CA | CD5363 | Other | RAILROAD MEDICARE |
| WV | DP5383 | Other | RAILROAD MEDICARE |
| CA | BZ008A | Medicare PIN | |
| AZ | Z131405 | Medicare PIN | |
| CA | W4815 | Medicare PIN | |
| PA | 160743 | Medicare PIN | |
| CA | CA7620 | Other | RAILROAD MEDICARE |
| CA | X05D000013 | Medicare PIN | |
| CA | ZZZ01399Z | Medicare PIN | |
| NV | V32893 | Medicare PIN | |
| ID | 119606410 | Medicare PIN | |
| NV | CG5410 | Other | RAILROAD MEDICARE |
| PA | DP5564 | Other | RAILROAD MEDICARE |
| CA | ZZZ24828Z | Medicare PIN | |
| CA | W4815C | Medicare PIN | |
| CA | ZZZ24833Z | Other | BLUE SHIELD PROVIDER NUMB |
| AZ | DP3049 | Other | RAILROAD MEDICARE 08/01/09 |
| WV | DP5383 | Other | RAILROAD MEDICARE |
| CA | CD5363 | Other | RAILROAD MEDICARE |
| CA | ZZZ24828Z | Other | BLUE SHIELD PROVIDER NUMB |
| CA | W4815F | Medicare PIN | |
| CA | W4815G | Medicare PIN | |
| CA | W4815I | Medicare PIN | |
| CA | ZZZ01444Z | Medicare PIN | |
| CA | ZZZ21294Z | Medicare PIN | |
| WV | 9383231 | Medicare PIN |
