Healthcare Provider Details

I. General information

NPI: 1245596501
Provider Name (Legal Business Name): OSAGE VALLEY PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 EXECUTIVE DR
OSAGE BEACH MO
65065-3496
US

IV. Provider business mailing address

985 EXECUTIVE DR
OSAGE BEACH MO
65065-3496
US

V. Phone/Fax

Practice location:
  • Phone: 573-348-4863
  • Fax: 573-348-4965
Mailing address:
  • Phone: 573-348-4863
  • Fax: 573-348-4965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMO109950
License Number StateMO

VIII. Authorized Official

Name: DAVID B HUANG
Title or Position: OWNER/OPERATOR
Credential: M.D.
Phone: 573-348-4863