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General NPI Number Information
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NPI Number | 1073883971
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Entity Type | Organization
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Legal Business Name | DAYTONA PLASTIC SURGERY, P.L.
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Dates
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Enumeration Date | 01/09/2012
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Last Update Date | 01/09/2012
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Provider Practice Location Address
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Address Line | 4606 S CLYDE MORRIS BLVD SUITE 1 L
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City | PORT ORANGE
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State | FL
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Zip | 32129-6404
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Country | US
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Telephone | 386-756-9009
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Fax | 386-756-3006
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Provider Business Mailing Address
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Address Line | 4606 S CLYDE MORRIS BLVD SUITE 1 L
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City | PORT ORANGE
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State | FL
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Zip | 32129-6404
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Country | US
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Telephone | 386-756-9009
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Fax | 386-756-3006
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. VIJAY J MORADIA
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Credential | M.B.,B.S.
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Telephone | 386-756-9009
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | ME 62606
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License Number State | FL
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