Healthcare Provider Details

I. General information

NPI: 1720629637
Provider Name (Legal Business Name): RALEIGH EYE AND FACE PLASTIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 10/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 LAKE BOONE TRL STE 103
RALEIGH NC
27607-7511
US

IV. Provider business mailing address

4201 LAKE BOONE TRL STE 103
RALEIGH NC
27607-7511
US

V. Phone/Fax

Practice location:
  • Phone: 919-626-8783
  • Fax: 844-456-0925
Mailing address:
  • Phone: 919-626-8783
  • Fax: 844-456-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. PRADEEP METTU
Title or Position: OWNER/MEMBER
Credential: MD
Phone: 919-626-8783