Healthcare Provider Details

I. General information

NPI: 1114960358
Provider Name (Legal Business Name): BLACKHAWK PLASTIC SURGERY, A MEDICAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 BLACKHAWK PLAZA CIR
DANVILLE CA
94506-4623
US

IV. Provider business mailing address

11999 SAN VICENTE BLVD STE 440
LOS ANGELES CA
90049-5131
US

V. Phone/Fax

Practice location:
  • Phone: 925-736-5757
  • Fax: 925-736-5763
Mailing address:
  • Phone: 310-440-3131
  • Fax: 310-472-9582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. STEPHEN J. RONAN
Title or Position: OWNER
Credential: M.D.
Phone: 925-736-5757