Provider Demographics
NPI:1619488848
Name:PACIFICO PLASTIC SURGERY MEDICAL PLLC
Entity Type:Organization
Organization Name:PACIFICO PLASTIC SURGERY MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:REICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-761-3700
Mailing Address - Street 1:2372 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6607
Mailing Address - Country:US
Mailing Address - Phone:718-761-3700
Mailing Address - Fax:
Practice Address - Street 1:2372 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6607
Practice Address - Country:US
Practice Address - Phone:718-761-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261299208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty