Healthcare Provider Details

I. General information

NPI: 1154598779
Provider Name (Legal Business Name): WESTLAKE DERMATOLOGY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 W FM 2147 SUITE 202
MARBLE FALLS TX
78654-6279
US

IV. Provider business mailing address

8825 BEE CAVE RD SUITE 100
AUSTIN TX
78746-4720
US

V. Phone/Fax

Practice location:
  • Phone: 512-328-3376
  • 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 Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateTX

VIII. Authorized Official

Name: GREGORY A NIKOLAIDIS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 512-328-3376