Healthcare Provider Details

I. General information

NPI: 1063464717
Provider Name (Legal Business Name): PLASTIC COSMETIC AND RESTORATIVE SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 RIDGEWAY AVENUE
ROCHESTER NY
14626
US

IV. Provider business mailing address

2640 RIDGEWAY AVENUE
ROCHESTER NY
14626
US

V. Phone/Fax

Practice location:
  • Phone: 585-225-0680
  • Fax: 585-225-1324
Mailing address:
  • Phone: 585-225-0680
  • Fax: 585-225-1324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number1052901
License Number StateNY

VIII. Authorized Official

Name: MR. DONALD JOSEPH CAPUANO
Title or Position: DIRECTOR
Credential: MD
Phone: 515-225-0680