Healthcare Provider Details

I. General information

NPI: 1164618435
Provider Name (Legal Business Name): DE OMILIA PLASTIC SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 SOUTH FINLEY AVE
BASKING RIDGE NJ
07920
US

IV. Provider business mailing address

96 SOUTH FINLEY AVE
BASKING RIDGE NJ
07920
US

V. Phone/Fax

Practice location:
  • Phone: 908-221-1136
  • Fax: 908-221-0482
Mailing address:
  • Phone: 908-221-1136
  • Fax: 908-221-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number25MA07315300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number25MA07315300
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number25MA07315300
License Number StateNJ

VIII. Authorized Official

Name: DR. DAVID Z EVDOKIMOW
Title or Position: OWNER
Credential: MD
Phone: 908-221-1136