Provider Demographics
NPI:1386913317
Name:WEST AVE PLASTIC SURGERY, PA
Entity type:Organization
Organization Name:WEST AVE PLASTIC SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:SUSSMAN
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-591-9283
Mailing Address - Street 1:2800 KIRBY DR
Mailing Address - Street 2:B212
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098
Mailing Address - Country:US
Mailing Address - Phone:713-559-9300
Mailing Address - Fax:888-878-1489
Practice Address - Street 1:2800 KIRBY DR
Practice Address - Street 2:B212
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77098-1273
Practice Address - Country:US
Practice Address - Phone:713-591-0283
Practice Address - Fax:888-878-1489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-20
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1585174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty