1609178961 NPI number — PLASTIC SURGERY SO CAL MEDICAL GROUP, INC.

Table of content: (NPI 1609178961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609178961 NPI number — PLASTIC SURGERY SO CAL MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PLASTIC SURGERY SO CAL MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DEVDAS WALI, MD
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609178961
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
250 W 1ST ST STE 116
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91711-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-624-4440
Provider Business Mailing Address Fax Number:
909-624-4448

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 W 1ST ST STE 116
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLAREMONT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-624-4440
Provider Business Practice Location Address Fax Number:
909-624-4448
Provider Enumeration Date:
11/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WALI
Authorized Official First Name:
DEVDAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
323-481-8430

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X , with the licence number:  A78108 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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