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General NPI Number Information
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NPI Number | 1144338302
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Entity Type | Organization
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Legal Business Name | ISLAND FACIAL PLASTIC AND ENT SURGERY, PA
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Dates
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Enumeration Date | 08/28/2006
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Last Update Date | 05/15/2012
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Provider Practice Location Address
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Address Line | 9981 S HEALTHPARK DR SUITE 259
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City | FORT MYERS
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State | FL
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Zip | 33908-3618
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Country | US
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Telephone | 239-481-9211
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Fax | 239-481-7568
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Provider Business Mailing Address
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Address Line | 9981 S HEALTHPARK DR SUITE 259
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City | FT MYERS
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State | FL
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Zip | 33908-3618
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Country | US
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Telephone | 239-481-9211
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Fax | 239-481-7568
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Authorized Official
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Title or Position | CEO/PRES
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Name | DR. JOHN BERTRAND DAVIS
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Credential | MD
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Telephone | 239-481-9211
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 0039739
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License Number State | FL
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