Provider Demographics
NPI:1306925375
Name:POMPERAUG PLASTIC SURGERY, LLC
Entity type:Organization
Organization Name:POMPERAUG PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEUNG-YEUN
Authorized Official - Middle Name:
Authorized Official - Last Name:WAITZE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-262-6200
Mailing Address - Street 1:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-0082
Mailing Address - Country:US
Mailing Address - Phone:203-262-6200
Mailing Address - Fax:203-262-6205
Practice Address - Street 1:22 POVERTY ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488
Practice Address - Country:US
Practice Address - Phone:203-262-6200
Practice Address - Fax:203-262-6205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH54455Medicare UPIN
CTC03456Medicare ID - Type Unspecified