MEDICARE: WESTLAKE DERMATOLOGY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1326692468
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTLAKE DERMATOLOGY, PA

Provider Business Mailing Address
First Line	:	8825 BEE CAVES RD STE 100
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78746-4721
Country	:	US
Telephone Number	:	512-328-3376
Fax Number	:	512-666-3767

Provider Business Practice Location Address
First Line	:	7515 GREENVILLE AVE STE 1030
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-3866
Country	:	US
Telephone Number	:	972-512-4800
Fax Number	:	214-484-9994

Authorized Official
Title or Position	:	OWNER
Name	:	GREGORY A. NIKOLAIDIS
Credential	:	MD
Telephone Number	:	512-328-3376

Provider Enumeration Date	:	07/26/2019
Last Update Date	:	10/20/2020

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