Provider Demographics
NPI:1033587589
Name:LA JOLLA FACIAL PLASTIC SURGERY INC
Entity Type:Organization
Organization Name:LA JOLLA FACIAL PLASTIC SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-461-0383
Mailing Address - Street 1:4765 CARMEL MOUNTAIN RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-6657
Mailing Address - Country:US
Mailing Address - Phone:858-461-0383
Mailing Address - Fax:858-430-2772
Practice Address - Street 1:4765 CARMEL MOUNTAIN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-6657
Practice Address - Country:US
Practice Address - Phone:858-461-0383
Practice Address - Fax:858-430-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA136426207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty