Healthcare Provider Details

I. General information

NPI: 1114332780
Provider Name (Legal Business Name): MAGNOLIA PLASTIC SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2404 CREEL LN
WESLEY CHAPEL FL
33544-4606
US

IV. Provider business mailing address

2404 CREEL LN
WESLEY CHAPEL FL
33544-4606
US

V. Phone/Fax

Practice location:
  • Phone: 813-977-3400
  • Fax: 330-773-3698
Mailing address:
  • Phone: 813-977-3400
  • Fax: 330-773-3698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberOS11384
License Number StateFL

VIII. Authorized Official

Name: ANAHITA AZHARIAN
Title or Position: OWNER
Credential: DO
Phone: 813-977-3400