Organization
WESTGATE DERMATOLOGY AND LASER CENTER, P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PAUL J KOSTUCHENKO MD (PRESIDENT)
(336) 768-1280
Entity
Organization
Contact information
Practice address
2020 PEACE HAVEN RD, WINSTON SALEM, NC 27106-4851
(336) 768-1280
Mailing address
2020 PEACE HAVEN RD, WINSTON SALEM, NC 27106-4851
(336) 768-1280
Taxonomy
Speciality
Code
Description
License number
State
207ND0900X
Dermatopathology Physician
Primary
—
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
5950698
—
NC
01
—
QPB766
SC MEDICAID
NC
05
—
QPB766
—
SC
Enumeration date
10/21/2008
Last updated
10/02/2012
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