=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063464717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PLASTIC COSMETIC AND RESTORATIVE SURGERY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 04/29/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2640 RIDGEWAY AVENUE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-225-0680
-----------------------------------------------------
Fax | 585-225-1324
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2640 RIDGEWAY AVENUE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-225-0680
-----------------------------------------------------
Fax | 585-225-1324
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. DONALD JOSEPH CAPUANO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 515-225-0680
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 1052901
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------