Healthcare Provider Details

I. General information

NPI: 1366980047
Provider Name (Legal Business Name): WESTOVER HILLS DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2017
Last Update Date: 02/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11212 STATE HIGHWAY 151 MEDICAL PLAZA 1, SUITE 320
SAN ANTONIO TX
78251-4498
US

IV. Provider business mailing address

11212 STATE HIGHWAY 151 MEDICAL PLAZA 1, SUITE 320
SAN ANTONIO TX
78251-4498
US

V. Phone/Fax

Practice location:
  • Phone: 830-276-2600
  • Fax: 866-886-2083
Mailing address:
  • Phone: 830-276-2600
  • Fax: 866-886-2083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberM9555
License Number StateTX

VIII. Authorized Official

Name: MOBOLAJI OPEOLA
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 469-644-0257