Provider Demographics
NPI:1588817084
Name:GLOW MEDISPA
Entity Type:Organization
Organization Name:GLOW MEDISPA
Other - Org Name:GLOW AESTHETICA AND SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SOOFIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUBBANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:516-801-1106
Mailing Address - Street 1:1 EXPRESSWAY PLZ
Mailing Address - Street 2:SUITE 115
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2047
Mailing Address - Country:US
Mailing Address - Phone:516-801-1106
Mailing Address - Fax:516-801-1312
Practice Address - Street 1:1 EXPRESSWAY PLZ
Practice Address - Street 2:SUITE 115
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2047
Practice Address - Country:US
Practice Address - Phone:516-801-1106
Practice Address - Fax:516-801-1312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY237435208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty