Provider Demographics
NPI:1184767014
Name:EAST VALLEY PLASTIC SURGERY, PC
Entity type:Organization
Organization Name:EAST VALLEY PLASTIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PLASTIC SURGEON
Authorized Official - Prefix:MR
Authorized Official - First Name:KHANG
Authorized Official - Middle Name:NGOC
Authorized Official - Last Name:THAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-894-8873
Mailing Address - Street 1:600 S. DOBSON RD SUITE E-36
Mailing Address - Street 2:EAST VALLEY PLASTIC SURGERY PC
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224
Mailing Address - Country:US
Mailing Address - Phone:480-894-8873
Mailing Address - Fax:480-894-8874
Practice Address - Street 1:600 S. DOBSON RD
Practice Address - Street 2:E-36
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224
Practice Address - Country:US
Practice Address - Phone:480-894-8873
Practice Address - Fax:480-894-8874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31020208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ758948Medicaid
AZ758948Medicaid
AZZ274204Medicare PIN