Healthcare Provider Details

I. General information

NPI: 1275624686
Provider Name (Legal Business Name): PLASTIC SURGERY INNOVATIONS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9933 DUPONT CIRCLE DR W STE 120
FORT WAYNE IN
46825-1629
US

IV. Provider business mailing address

9933 DUPONT CIRCLE DR W STE 120
FORT WAYNE IN
46825-1629
US

V. Phone/Fax

Practice location:
  • Phone: 260-490-4673
  • Fax: 260-490-2165
Mailing address:
  • Phone: 260-490-4673
  • Fax: 260-490-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number StateIN

VIII. Authorized Official

Name: DR. JOSEPH M. MLAKAR
Title or Position: PRESIDENT/OWNER/PHYSICIAN
Credential: M.D.
Phone: 260-490-4673