Healthcare Provider Details

I. General information

NPI: 1891029476
Provider Name (Legal Business Name): WESTLAKE DERMATOLOGY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 09/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 RR 620 N SUITE 200
LAKEWAY TX
78734-3910
US

IV. Provider business mailing address

6836 BEE CAVES RD SUITE 111
AUSTIN TX
78746-5059
US

V. Phone/Fax

Practice location:
  • Phone: 512-610-0549
  • Fax: 512-306-0222
Mailing address:
  • Phone: 512-328-3376
  • Fax: 512-306-0222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: GREGORY NIKOLAIDIS
Title or Position: OWNER/PRESIDENT
Credential: MD
Phone: 512-328-3376