Provider Demographics
NPI:1255502753
Name:MOUCHANTAT PLASTIC SURGERY PC
Entity Type:Organization
Organization Name:MOUCHANTAT PLASTIC SURGERY PC
Other - Org Name:JOHN M PAV MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:MOUCHANTAT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-232-8585
Mailing Address - Street 1:3280 WADSWORTH BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WHEAT RIDGE
Mailing Address - State:CO
Mailing Address - Zip Code:80033-4640
Mailing Address - Country:US
Mailing Address - Phone:303-232-8585
Mailing Address - Fax:303-232-3304
Practice Address - Street 1:3280 WADSWORTH BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WHEAT RIDGE
Practice Address - State:CO
Practice Address - Zip Code:80033-4640
Practice Address - Country:US
Practice Address - Phone:303-232-8585
Practice Address - Fax:303-232-3304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCS4008Medicare PIN