Basic Information
Provider Information | |||||||||
NPI: | 1407088081 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | J. ROBERT WEST, M.D., INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WEST DERMATOLOGY OF ARIZONA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2285 CORPORATE CIR STE 200 | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | NV | ||||||||
PostalCode: | 890747759 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023602763 | ||||||||
FaxNumber: | 9497832880 | ||||||||
Practice Location | |||||||||
Address1: | 1729 N TREKELL RD STE 124 | ||||||||
Address2: |   | ||||||||
City: | CASA GRANDE | ||||||||
State: | AZ | ||||||||
PostalCode: | 851222215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5204217100 | ||||||||
FaxNumber: | 5204211300 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2009 | ||||||||
LastUpdateDate: | 02/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLANCHARD | ||||||||
AuthorizedOfficialFirstName: | LUCIUS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 7023602100 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 40312 | AZ | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | DP3049 | 01 | AZ | RAILROAD MEDICARE 08/01/09 | OTHER |