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	208200000X	Plastic Surgery Physician
2	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1437617255
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	:	2132 BISSONNET ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77005-1508
Country	:	US
Telephone Number	:	512-615-2738
Fax Number	:	281-205-3503

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

Provider Enumeration Date	:	03/11/2019
Last Update Date	:	03/11/2019

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Directions to “WESTLAKE DERMATOLOGY, PA ” Practice Location

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