Provider Demographics
NPI:1598105983
Name:PLASTIC AND RECONSTRUCTIVE SURGERY OF ATLANTA
Entity type:Organization
Organization Name:PLASTIC AND RECONSTRUCTIVE SURGERY OF ATLANTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:WANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-991-0319
Mailing Address - Street 1:2795 PEACHTREE RD NE
Mailing Address - Street 2:UNIT 309
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-3611
Mailing Address - Country:US
Mailing Address - Phone:917-991-0319
Mailing Address - Fax:718-672-3280
Practice Address - Street 1:1218 W PACES FERRY RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2308
Practice Address - Country:US
Practice Address - Phone:917-991-0319
Practice Address - Fax:718-672-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-28
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0700002086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty