Provider Demographics
NPI:1306976808
Name:FACIAL RECONSTRUCTIVE SURGICAL AND MEDICAL CENTER
Entity type:Organization
Organization Name:FACIAL RECONSTRUCTIVE SURGICAL AND MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ODERIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-328-0511
Mailing Address - Street 1:750 WELCH RD.
Mailing Address - Street 2:SUITE 317
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-1510
Mailing Address - Country:US
Mailing Address - Phone:650-328-0511
Mailing Address - Fax:650-328-3419
Practice Address - Street 1:750 WELCH RD.
Practice Address - Street 2:SUITE 317
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1510
Practice Address - Country:US
Practice Address - Phone:650-328-0511
Practice Address - Fax:650-328-3419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4021229OtherCOMMERCIAL #