Provider Demographics
NPI:1144338302
Name:ISLAND FACIAL PLASTIC AND ENT SURGERY, PA
Entity type:Organization
Organization Name:ISLAND FACIAL PLASTIC AND ENT SURGERY, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BERTRAND
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-481-9211
Mailing Address - Street 1:9981 S HEALTHPARK DR
Mailing Address - Street 2:SUITE 259
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-3618
Mailing Address - Country:US
Mailing Address - Phone:239-481-9211
Mailing Address - Fax:239-481-7568
Practice Address - Street 1:9981 S HEALTHPARK DR
Practice Address - Street 2:SUITE 259
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-3618
Practice Address - Country:US
Practice Address - Phone:239-481-9211
Practice Address - Fax:239-481-7568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0039739261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL11986OtherBC/BS
FLB30678Medicare UPIN