MEDICARE: GEMINI PLASTIC SURGERY ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician

General Provider Information

NPI Number	:	1356938948
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEMINI PLASTIC SURGERY ASSOCIATES

Provider Business Mailing Address
First Line	:	10888 FOOTHILL BLVD
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-7651
Country	:	US
Telephone Number	:	909-463-0715
Fax Number	:

Provider Business Practice Location Address
First Line	:	10888 FOOTHILL BLVD
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91730-7651
Country	:	US
Telephone Number	:	909-463-0715
Fax Number	:	909-463-0675

Authorized Official
Title or Position	:	PRESIDENT
Name	:	GEMINI PLASTIC SURGERY
Credential	:	MD
Telephone Number	:	909-463-0715

Provider Enumeration Date	:	12/29/2020
Last Update Date	:	04/29/2025

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