MEDICARE: WEST DERMATOLOGY OF ARIZONA, INC

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

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CS4930	OTHER	AZ	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1902850597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEST DERMATOLOGY OF ARIZONA, INC

Provider Business Mailing Address
First Line	:	PO BOX 2048
Second Line	:
City	:	REDLANDS
State	:	CA
Zip	:	92373-0641
Country	:	US
Telephone Number	:	909-335-8649
Fax Number	:	909-335-1994

Provider Business Practice Location Address
First Line	:	560 W BROWN RD
Second Line	:	SUITE 4001
City	:	MESA
State	:	AZ
Zip	:	85201-3221
Country	:	US
Telephone Number	:	480-962-4269
Fax Number	:	480-962-3702

Authorized Official
Title or Position	:	PRESIDENT
Name	:	J. ROBERT WEST SR.
Credential	:	M.D.
Telephone Number	:	909-335-8649

Provider Enumeration Date	:	05/19/2006
Last Update Date	:	01/06/2009

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