MEDICARE: TANTAWI PLASTICS COSMETIC VASCULAR SURGERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician	A126218	CA
2	2082S0099X	Plastic Surgery Within the Head and Neck (Plastic Surgery) Physician	A126218	CA
3	2082S0105X	Surgery of the Hand (Plastic Surgery) Physician	A126218	CA
4	2086S0102X	Surgical Critical Care Physician	A126218	CA
5	2086S0127X	Trauma Surgery Physician	A126218	CA
6	2086S0129X	Vascular Surgery Physician	A126218	CA
7	2086S0122X	Plastic and Reconstructive Surgery Physician	A126218	CA

General Provider Information

NPI Number	:	1891193348
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TANTAWI PLASTICS COSMETIC VASCULAR SURGERY

Provider Business Mailing Address
First Line	:	6935 SPRING VALLEY LN
Second Line	:
City	:	EXPORT
State	:	PA
Zip	:	15632-2644
Country	:	US
Telephone Number	:	646-232-8298
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 E VISTA CHINO # A7-427
Second Line	:
City	:	PALM SPRINGS
State	:	CA
Zip	:	92262-3559
Country	:	US
Telephone Number	:	646-232-8298
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DIYA TANTAWI
Credential	:	M.D.
Telephone Number	:	646-232-8298

Provider Enumeration Date	:	12/16/2014
Last Update Date	:	12/16/2014

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