Provider Demographics
NPI:1053521021
Name:DERMATOLOGY WEST, LLC
Entity type:Organization
Organization Name:DERMATOLOGY WEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:LOREN
Authorized Official - Last Name:WAGAMON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-858-3176
Mailing Address - Street 1:1445 CASTRO ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-3717
Mailing Address - Country:US
Mailing Address - Phone:440-858-3176
Mailing Address - Fax:
Practice Address - Street 1:26410 CENTER RIDGE RD
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-4067
Practice Address - Country:US
Practice Address - Phone:440-858-3176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1780758003OtherPERSONAL NPI
CA1780758003OtherPERSONAL NPI