Healthcare Provider Details

I. General information

NPI: 1659442531
Provider Name (Legal Business Name): CENTER FOR PLASTIC & RECONSTRUCTIVE SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 04/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E RIDGEWOOD AVE
PARAMUS NJ
07652-4038
US

IV. Provider business mailing address

PO BOX 678688
DALLAS TX
75267-8688
US

V. Phone/Fax

Practice location:
  • Phone: 201-967-1212
  • Fax: 201-262-6270
Mailing address:
  • Phone: 972-758-3595
  • Fax: 972-599-9604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number36477
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. PAUL M. PARKER
Title or Position: OWNER
Credential: M.D.
Phone: 201-967-1212