Provider Demographics
NPI:1336980069
Name:KODA PLASTIC SURGERY
Entity type:Organization
Organization Name:KODA PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAGHIB
Authorized Official - Suffix:
Authorized Official - Credentials:MEDICAL ASSISTANT
Authorized Official - Phone:616-914-8894
Mailing Address - Street 1:9097 E DESERT COVE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-6276
Mailing Address - Country:US
Mailing Address - Phone:616-914-8894
Mailing Address - Fax:480-701-4990
Practice Address - Street 1:9097 E DESERT COVE AVE STE 100
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-6276
Practice Address - Country:US
Practice Address - Phone:616-914-8894
Practice Address - Fax:480-701-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-05
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty