Provider Demographics
NPI:1164618435
Name:DE OMILIA PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:DE OMILIA PLASTIC SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:Z
Authorized Official - Last Name:EVDOKIMOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-221-1136
Mailing Address - Street 1:96 SOUTH FINLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920
Mailing Address - Country:US
Mailing Address - Phone:908-221-1136
Mailing Address - Fax:908-221-0482
Practice Address - Street 1:96 SOUTH FINLEY AVE
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920
Practice Address - Country:US
Practice Address - Phone:908-221-1136
Practice Address - Fax:908-221-0482
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-20
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07315300204E00000X, 208200000X, 2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ087461Medicare Oscar/Certification