Provider Demographics
NPI:1205304995
Name:EAST VALLEY PEDIATRIC PLASTIC SURGERY, PLC
Entity type:Organization
Organization Name:EAST VALLEY PEDIATRIC PLASTIC SURGERY, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:WORKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-658-0123
Mailing Address - Street 1:1900 W CARLA VISTA DR # 6367
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-8201
Mailing Address - Country:US
Mailing Address - Phone:614-556-0875
Mailing Address - Fax:480-383-6429
Practice Address - Street 1:1432 S DOBSON RD STE 401
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4777
Practice Address - Country:US
Practice Address - Phone:480-658-0123
Practice Address - Fax:480-383-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty