Healthcare Provider Details

I. General information

NPI: 1225448921
Provider Name (Legal Business Name): THE PALM BEACH CENTER FOR FACIAL PLASTIC & LASER SURGERY, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4495 MILITARY TRL STE 202
JUPITER FL
33458
US

IV. Provider business mailing address

4495 MILITARY TRL SUITE 202
JUPITER FL
33458-4839
US

V. Phone/Fax

Practice location:
  • Phone: 561-429-5403
  • Fax: 561-626-6277
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberME117560
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberME134770
License Number StateFL

VIII. Authorized Official

Name: DR. JEAN PAUL AZZI
Title or Position: OWNER
Credential: M.D.
Phone: 561-429-5403