Provider Demographics
NPI:1770129058
Name:NORTHEAST PLASTIC SURGERY PLLC
Entity type:Organization
Organization Name:NORTHEAST PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAREEF
Authorized Official - Middle Name:
Authorized Official - Last Name:JANDALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-604-5865
Mailing Address - Street 1:21 SOUTHPORT TER
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:245 5TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-8728
Practice Address - Country:US
Practice Address - Phone:917-708-0018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty