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General NPI Number Information
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NPI Number | 1386913317
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Entity Type | Organization
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Legal Business Name | WEST AVE PLASTIC SURGERY, PA
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Dates
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Enumeration Date | 12/20/2011
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Last Update Date | 05/09/2012
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Provider Practice Location Address
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Address Line | 2800 KIRBY DR B212
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City | HOUSTON
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State | TX
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Zip | 77098-1273
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Country | US
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Telephone | 713-591-0283
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Fax | 888-878-1489
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Provider Business Mailing Address
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Address Line | 2800 KIRBY DR B212
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City | HOUSTON
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State | TX
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Zip | 77098
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Country | US
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Telephone | 713-559-9300
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Fax | 888-878-1489
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. FORREST SUSSMAN ROTH
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Credential | M.D.
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Telephone | 713-591-9283
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | P1585
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License Number State | TX
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