Provider Demographics
NPI:1386969384
Name:JEUNEDERM COSMETIC SURGERY CENTER, INC.
Entity type:Organization
Organization Name:JEUNEDERM COSMETIC SURGERY CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ABDOLREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:TABRIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-263-2223
Mailing Address - Street 1:991 MONTAGUE EXPRESS WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035
Mailing Address - Country:US
Mailing Address - Phone:408-263-2223
Mailing Address - Fax:408-263-2225
Practice Address - Street 1:991 MONTAGUE EXPY
Practice Address - Street 2:SUITE 202
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6809
Practice Address - Country:US
Practice Address - Phone:408-263-2223
Practice Address - Fax:408-263-2225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-01
Last Update Date:2010-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH11356Medicare UPIN