=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053809780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. KITTO PLASTIC SURGERY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2018
-----------------------------------------------------
Last Update Date | 11/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 JOHNSTON WILLIS DR STE 110
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 804-787-4927
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 JOHNSTON WILLIS DR STE 110
-----------------------------------------------------
City | NORTH CHESTERFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23235-4872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | INZHILI K ISMAIL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 804-787-4927
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------