Healthcare Provider Details

I. General information

NPI: 1326462540
Provider Name (Legal Business Name): VISAGE FACIAL PLASTIC SURGERY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2014
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19275 W CAPITOL DR SUITE 205
BROOKFIELD WI
53045-2742
US

IV. Provider business mailing address

19275 W CAPITOL DR SUITE 205
BROOKFIELD WI
53045-2742
US

V. Phone/Fax

Practice location:
  • Phone: 262-701-7040
  • Fax:
Mailing address:
  • Phone: 262-701-7040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ANAND D PATEL
Title or Position: OWNER
Credential: M.D.
Phone: 323-839-8022