Healthcare Provider Details

I. General information

NPI: 1568815207
Provider Name (Legal Business Name): PLASTIC & RECONSTRUCTIVE SURGERY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2016
Last Update Date: 07/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2581 SAMARITAN DR STE 102
SAN JOSE CA
95124-4112
US

IV. Provider business mailing address

2581 SAMARITAN DR STE 102
SAN JOSE CA
95124-4112
US

V. Phone/Fax

Practice location:
  • Phone: 888-566-6663
  • Fax:
Mailing address:
  • Phone: 888-566-6663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberG048588
License Number StateCA

VIII. Authorized Official

Name: VINCENT D LEPORE JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 888-566-6663