Healthcare Provider Details

I. General information

NPI: 1861979288
Provider Name (Legal Business Name): CASSILETH RECONSTRUCTIVE SURGEONS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2018
Last Update Date: 02/12/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N BEDFORD DR SUITE 103
BEVERLY HILLS CA
90210-4323
US

IV. Provider business mailing address

436 N BEDFORD DR SUITE 103
BEVERLY HILLS CA
90210-4323
US

V. Phone/Fax

Practice location:
  • Phone: 310-278-8200
  • Fax: 424-202-3769
Mailing address:
  • Phone: 310-278-8200
  • Fax: 424-202-3769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: GREGORY CASSILETH
Title or Position: CFO
Credential:
Phone: 310-278-8200