Provider Demographics
NPI:1639225188
Name:ASSOCIATES FOR PLASTIC SURGERY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:ASSOCIATES FOR PLASTIC SURGERY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMOOT
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:858-587-9850
Mailing Address - Street 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-587-9850
Mailing Address - Fax:858-622-2066
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-587-9850
Practice Address - Fax:858-622-2066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21358208200000X
CAG62141208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41259Medicare UPIN
CAB58067Medicare UPIN