Provider Demographics
NPI:1326462540
Name:VISAGE FACIAL PLASTIC SURGERY SC
Entity Type:Organization
Organization Name:VISAGE FACIAL PLASTIC SURGERY SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANAND
Authorized Official - Middle Name:D
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-839-8022
Mailing Address - Street 1:19275 W CAPITOL DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2742
Mailing Address - Country:US
Mailing Address - Phone:262-701-7040
Mailing Address - Fax:
Practice Address - Street 1:19275 W CAPITOL DR
Practice Address - Street 2:SUITE 205
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2742
Practice Address - Country:US
Practice Address - Phone:262-701-7040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-07
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & NeckGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400139036Medicare PIN
WIK100139006Medicare PIN