Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207ND0101X | MOHS-Micrographic Surgeon | 44204 | CT |
N | 207ND0101X | MOHS-Micrographic Surgeon | G61079 | CA |
NPI | 1487606117 |
---|---|
Provider Name | Dr. John Robert West JR. |
First Address | Mystic, CT 06355 |
Second Address | Mystic, CT 06355 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2006 |
Last Update Date | 28/10/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
010044204CT01 | BLUE CROSS BLUE SHIELD (01) | CT |
E56217 | (02) | CT |