Healthcare Provider Details

I. General information

NPI: 1770787087
Provider Name (Legal Business Name): PHYSICIAN'S INSTITUTE OF COSMETIC AND RECONSTRUCTIVE SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3449 JOHNSON ST
HOLLYWOOD FL
33021-5420
US

IV. Provider business mailing address

3449 JOHNSON ST
HOLLYWOOD FL
33021-5420
US

V. Phone/Fax

Practice location:
  • Phone: 954-964-4113
  • Fax: 954-963-8121
Mailing address:
  • Phone: 954-964-4113
  • Fax: 954-963-8121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME64761
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME62894
License Number StateFL

VIII. Authorized Official

Name: MRS. WANDA DITTHARDT
Title or Position: OFFICE MANAGER
Credential:
Phone: 954-964-4113