1184767014 NPI number — EAST VALLEY PLASTIC SURGERY, PC

Table of content: (NPI 1184767014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184767014 NPI number — EAST VALLEY PLASTIC SURGERY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST VALLEY PLASTIC SURGERY, PC
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:
Provider Other Organization Name Type Code:
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:
1184767014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
600 S. DOBSON RD SUITE E-36
Provider Second Line Business Mailing Address:
EAST VALLEY PLASTIC SURGERY PC
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-894-8873
Provider Business Mailing Address Fax Number:
480-894-8874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 S. DOBSON RD
Provider Second Line Business Practice Location Address:
E-36
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-894-8873
Provider Business Practice Location Address Fax Number:
480-894-8874
Provider Enumeration Date:
02/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THAI
Authorized Official First Name:
KHANG
Authorized Official Middle Name:
NGOC
Authorized Official Title or Position:
PLASTIC SURGEON
Authorized Official Telephone Number:
480-894-8873

Provider Taxonomy Codes

  • Taxonomy code: 208200000X , with the licence number:  31020 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 758948 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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