Provider Demographics
NPI:1073883971
Name:DAYTONA PLASTIC SURGERY, P.L.
Entity Type:Organization
Organization Name:DAYTONA PLASTIC SURGERY, P.L.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORADIA
Authorized Official - Suffix:
Authorized Official - Credentials:MB,BS
Authorized Official - Phone:386-756-9009
Mailing Address - Street 1:4606 S CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 1 L
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6404
Mailing Address - Country:US
Mailing Address - Phone:386-756-9009
Mailing Address - Fax:386-756-3006
Practice Address - Street 1:4606 S CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 1 L
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32129-6404
Practice Address - Country:US
Practice Address - Phone:386-756-9009
Practice Address - Fax:386-756-3006
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-09
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 62606261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center