Provider Demographics
NPI:1154639052
Name:PLASTIC & COSMETIC SURGERY INSTITUTE PC
Entity Type:Organization
Organization Name:PLASTIC & COSMETIC SURGERY INSTITUTE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-691-0200
Mailing Address - Street 1:1051 W SHERMAN AVE
Mailing Address - Street 2:BLDG 2, SUITE A
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6931
Mailing Address - Country:US
Mailing Address - Phone:856-691-0200
Mailing Address - Fax:856-691-5984
Practice Address - Street 1:1051 W SHERMAN AVE
Practice Address - Street 2:BLDG 2, SUITE A
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6931
Practice Address - Country:US
Practice Address - Phone:856-691-0200
Practice Address - Fax:856-691-5984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06143100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6527400Medicaid
NJ6527400Medicaid