Provider Demographics
NPI:1609178961
Name:PLASTIC SURGERY SO CAL MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:PLASTIC SURGERY SO CAL MEDICAL GROUP, INC.
Other - Org Name:DEVDAS WALI, MD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEVDAS
Authorized Official - Middle Name:
Authorized Official - Last Name:WALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-481-8430
Mailing Address - Street 1:250 W 1ST ST STE 116
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4740
Mailing Address - Country:US
Mailing Address - Phone:909-624-4440
Mailing Address - Fax:909-624-4448
Practice Address - Street 1:250 W 1ST ST STE 116
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711
Practice Address - Country:US
Practice Address - Phone:909-624-4440
Practice Address - Fax:909-624-4448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-18
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA781082086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty