Healthcare Provider Details

I. General information

NPI: 1194997262
Provider Name (Legal Business Name): TRAIKOVICH COSMETIC SURGERY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2008
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19636 N 27TH AVE STE 206
PHOENIX AZ
85027-4015
US

IV. Provider business mailing address

9967 E DESERT BEAUTY DR
SCOTTSDALE AZ
85255-2579
US

V. Phone/Fax

Practice location:
  • Phone: 623-516-0930
  • Fax: 623-580-9084
Mailing address:
  • Phone: 602-317-9347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number StateAZ

VIII. Authorized Official

Name: MRS. SUSAN LORRAINE TRAIKOVICH
Title or Position: ADMINISTRATOR
Credential:
Phone: 602-317-9347