NPIMap

Organization Active NPI

Westgate Dermatology and Laser Center, P.a.

  • Dermatopathology Physician
  • Winston Salem, NC
National Provider Identifier
1821240995
Registry record updated Oct 2, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatopathology PhysicianTaxonomy code 207ND0900X
Legal business name
WESTGATE DERMATOLOGY AND LASER CENTER, P.A.
Practice address
2020 Peace Haven Rd
Winston Salem, NC 27106-4851
Phone
(336) 768-1280
NPI assigned
Oct 21, 2008
Last updated
Oct 2, 2012By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 2, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Paul J Kostuchenko, MDNPI 1972591055
Title
President
Phone
(336) 768-1280

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatopathology PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207ND0900X NC Primary

Addresses

Primary practice location

2020 Peace Haven Rd
Winston Salem, NC 27106-4851

Mailing address

2020 Peace Haven Rd
Winston Salem, NC 27106-4851
Phone (336) 768-1280

Other identifiers 3

IdentifierTypeStateIssuer
QPB766OtherNCSC MEDICAID
QPB766MedicaidSC
5950698MedicaidNC

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090310000490 NC Part B Supplier - Clinic/Group Practice 8325104714 Receives reassigned benefits from 10 practitioners
Practice locations: Kernersville, NC; Winston Salem, NC

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
34D1094366Westgate Dermatology and Laser Center, PA2020 Peace Haven Road, Winston Salem, NC 27106ComplianceJul 31, 2026

National Provider Directory

National Provider Directory

Locations

2020 N Peace Haven Rd
Winston Salem, NC 27106
Phone (336) 768-1280

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1224547200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1349136000000",
    "number": "1821240995",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2020 PEACE HAVEN RD",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271064851",
            "telephone_number": "336-768-1280"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2020 PEACE HAVEN RD",
            "city": "WINSTON SALEM",
            "state": "NC",
            "postal_code": "271064851",
            "telephone_number": "336-768-1280"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WESTGATE DERMATOLOGY AND LASER CENTER, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-10-21",
        "last_updated": "2012-10-02",
        "status": "A",
        "authorized_official_last_name": "KOSTUCHENKO",
        "authorized_official_first_name": "PAUL",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "336-768-1280",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207ND0900X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dermatology, Dermatopathology",
            "state": "NC",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "SC MEDICAID",
            "identifier": "QPB766",
            "state": "NC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "QPB766",
            "state": "SC"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5950698",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Winston Salem, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 2, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.