Provider Demographics
NPI:1770801086
Name:MONA LISA COSMETIC SURGERY CENTER
Entity type:Organization
Organization Name:MONA LISA COSMETIC SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RAMTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KASSIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACS
Authorized Official - Phone:973-692-9300
Mailing Address - Street 1:1176 HAMBURG TPKE
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5069
Mailing Address - Country:US
Mailing Address - Phone:973-692-9300
Mailing Address - Fax:973-692-9301
Practice Address - Street 1:1176 HAMBURG TPKE
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-5069
Practice Address - Country:US
Practice Address - Phone:973-692-9300
Practice Address - Fax:973-692-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207N00000X
NJMA0657312086S0122X, 207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF72517Medicare UPIN