Healthcare Provider Details

I. General information

NPI: 1467936831
Provider Name (Legal Business Name): JOHNNY MAO, MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2018
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S ORANGE CENTER RD
ORANGE CT
06477-3349
US

IV. Provider business mailing address

200 S ORANGE CENTER RD
ORANGE CT
06477-3349
US

V. Phone/Fax

Practice location:
  • Phone: 203-907-0501
  • Fax: 203-907-0503
Mailing address:
  • Phone: 203-907-0501
  • Fax: 203-907-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. JOHNNY MAO
Title or Position: PRESIDENT
Credential: MD
Phone: 203-907-0501