MEDICARE: WESTLAKE DERMATOLOGY PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ND0900X	Dermatopathology Physician		TX
2	207N00000X	Dermatology Physician		TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00591T	OTHER	TX	BCBS OF TEXAS GROUP#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477678993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTLAKE DERMATOLOGY PA

Provider Business Mailing Address
First Line	:	8825 BEE CAVE RD
Second Line	:	SUITE 100
City	:	AUSTIN
State	:	TX
Zip	:	78746-4719
Country	:	US
Telephone Number	:	512-328-3376
Fax Number	:	512-306-0222

Provider Business Practice Location Address
First Line	:	1760 ROUND ROCK AVE
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78681-4217
Country	:	US
Telephone Number	:	512-583-3376
Fax Number	:	512-306-0222

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. GREGORY NIKOLAIDIS
Credential	:	MD
Telephone Number	:	512-328-3376

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	11/05/2015

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Directions to “WESTLAKE DERMATOLOGY PA ” Practice Location

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