Healthcare Provider Details

I. General information

NPI: 1841476041
Provider Name (Legal Business Name): THE ISSE INSTITUTE OF COSMETIC SURGERY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S BUENA VISTA ST SUITE 250
BURBANK CA
91505-4569
US

IV. Provider business mailing address

201 S BUENA VISTA ST SUITE 250
BURBANK CA
91505-4569
US

V. Phone/Fax

Practice location:
  • Phone: 818-557-6595
  • Fax: 818-557-6598
Mailing address:
  • Phone: 818-557-6595
  • Fax: 818-557-6598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA34958
License Number StateCA

VIII. Authorized Official

Name: DR. NICANOR G. ISSE
Title or Position: MEDICAL DIRECTOR/THE ISSE INSTITUTE
Credential: M.D.
Phone: 818-557-6595