Healthcare Provider Details

I. General information

NPI: 1013254036
Provider Name (Legal Business Name): BINGHAMTON PLASTIC SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 RIVERSIDE DR SUITE 106
BINGHAMTON NY
13905-4176
US

IV. Provider business mailing address

161 RIVERSIDE DR SUITE 106
BINGHAMTON NY
13905-4176
US

V. Phone/Fax

Practice location:
  • Phone: 607-729-0101
  • Fax: 607-729-5693
Mailing address:
  • Phone: 607-729-0101
  • Fax: 607-729-5693

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number134180
License Number StateNY

VIII. Authorized Official

Name: DR. ARMANDO B MATA
Title or Position: PRESIDENT
Credential: MD
Phone: 607-729-0101