Provider Demographics
NPI:1487606117
Name:WEST, JOHN ROBERT JR (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ROBERT
Last Name:WEST
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 WATER STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355
Mailing Address - Country:US
Mailing Address - Phone:860-572-9994
Mailing Address - Fax:860-572-9930
Practice Address - Street 1:34 WATER STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355
Practice Address - Country:US
Practice Address - Phone:860-572-9994
Practice Address - Fax:860-572-9930
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61079207ND0101X
CT44204207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010044204CT01OtherBLUE CROSS BLUE SHIELD
CT010044204CT01OtherBLUE CROSS BLUE SHIELD
CTE56217Medicare UPIN