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General NPI Number Information
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NPI Number | 1821240995
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Entity Type | Organization
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Legal Business Name | WESTGATE DERMATOLOGY AND LASER CENTER, P.A.
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Dates
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Enumeration Date | 10/21/2008
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Last Update Date | 10/02/2012
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Provider Practice Location Address
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Address Line | 2020 PEACE HAVEN RD
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City | WINSTON SALEM
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State | NC
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Zip | 27106-4851
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Country | US
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Telephone | 336-768-1280
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Fax |
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Provider Business Mailing Address
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Address Line | 2020 PEACE HAVEN RD
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City | WINSTON SALEM
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State | NC
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Zip | 27106-4851
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Country | US
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Telephone | 336-768-1280
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | PAUL J KOSTUCHENKO
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Credential | MD
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Telephone | 336-768-1280
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0900X
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Taxonomy Name | Dermatopathology Physician
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License Number |
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License Number State | NC
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