Healthcare Provider Details

I. General information

NPI: 1821240995
Provider Name (Legal Business Name): WESTGATE DERMATOLOGY AND LASER CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2008
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 PEACE HAVEN RD
WINSTON SALEM NC
27106-4851
US

IV. Provider business mailing address

2020 PEACE HAVEN RD
WINSTON SALEM NC
27106-4851
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-1280
  • Fax:
Mailing address:
  • Phone: 336-768-1280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: PAUL J KOSTUCHENKO
Title or Position: PRESIDENT
Credential: MD
Phone: 336-768-1280