Healthcare Provider Details

I. General information

NPI: 1174793277
Provider Name (Legal Business Name): GENESIS PLASTIC SURGERY AND MEDICAL SPA INC.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 S KELLY AVE
EDMOND OK
73013
US

IV. Provider business mailing address

2505 S KELLY AVE
EDMOND OK
73013-5796
US

V. Phone/Fax

Practice location:
  • Phone: 405-340-9949
  • Fax:
Mailing address:
  • Phone: 405-340-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number20347
License Number StateOK

VIII. Authorized Official

Name: DR. JAYESH PANCHAL
Title or Position: PHYSICIAN
Credential: MD
Phone: 405-340-9949