Provider Demographics
NPI:1568770428
Name:GOLD COAST PLASTIC SURGERY AND LASER CENTER, LLC
Entity Type:Organization
Organization Name:GOLD COAST PLASTIC SURGERY AND LASER CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANG
Authorized Official - Middle Name:SOO
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-233-4050
Mailing Address - Street 1:999 SUMMER ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5546
Mailing Address - Country:US
Mailing Address - Phone:203-920-1444
Mailing Address - Fax:866-920-5178
Practice Address - Street 1:999 SUMMER ST
Practice Address - Street 2:SUITE 401
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5546
Practice Address - Country:US
Practice Address - Phone:203-920-1444
Practice Address - Fax:866-920-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT048229208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH-88270Medicare UPIN