Healthcare Provider Details

I. General information

NPI: 1265086045
Provider Name (Legal Business Name): WESTLAKE DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 BROADWAY AVE
ALAMO HEIGHTS TX
78209
US

IV. Provider business mailing address

8825 BEE CAVES RD STE 100
AUSTIN TX
78746-4721
US

V. Phone/Fax

Practice location:
  • Phone: 210-802-0085
  • Fax: 210-775-0082
Mailing address:
  • Phone: 512-328-3376
  • Fax: 512-666-3767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY A. NIKOLAIDIS
Title or Position: OWNER
Credential: MD
Phone: 512-328-3376