Healthcare Provider Details

I. General information

NPI: 1043404296
Provider Name (Legal Business Name): FACIAL PLASTIC SURGERY EARS, NOSE, AND THROAT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 08/30/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 W ALTO RD
KOKOMO IN
46902-4840
US

IV. Provider business mailing address

2220 W ALTO RD
KOKOMO IN
46902-4840
US

V. Phone/Fax

Practice location:
  • Phone: 765-455-2577
  • Fax:
Mailing address:
  • Phone: 765-455-2577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. BANIPAL HOVHANESSIAN
Title or Position: DR./OWNER
Credential: MD
Phone: 765-455-2577