Healthcare Provider Details

I. General information

NPI: 1568523793
Provider Name (Legal Business Name): WEST DERMATOLOGY OF NORTHERN CALIFORNIA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1444 FLORIDA AVE SUITE 201
MODESTO CA
95350-4400
US

IV. Provider business mailing address

101 E REDLANDS BLVD SUITE 212
REDLANDS CA
92373-4775
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-4384
  • Fax: 209-526-4385
Mailing address:
  • Phone: 909-335-8649
  • Fax: 909-335-1994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. J ROBERT WEST SR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 909-335-8649