Provider Demographics
NPI:1073755443
Name:ELEVATION PLASTIC SURGERY, PC
Entity Type:Organization
Organization Name:ELEVATION PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:RYO
Authorized Official - Last Name:OTAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:203-752-0015
Mailing Address - Street 1:60 TEMPLE ST
Mailing Address - Street 2:SUITE 4B
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2716
Mailing Address - Country:US
Mailing Address - Phone:203-752-0015
Mailing Address - Fax:203-772-2814
Practice Address - Street 1:60 TEMPLE ST
Practice Address - Street 2:SUITE 4B
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2716
Practice Address - Country:US
Practice Address - Phone:203-752-0015
Practice Address - Fax:203-772-2814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT046053208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty