Provider Demographics
NPI:1174793277
Name:GENESIS PLASTIC SURGERY AND MEDICAL SPA INC.,P.C.
Entity type:Organization
Organization Name:GENESIS PLASTIC SURGERY AND MEDICAL SPA INC.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYESH
Authorized Official - Middle Name:
Authorized Official - Last Name:PANCHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-340-9949
Mailing Address - Street 1:2505 S KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-5796
Mailing Address - Country:US
Mailing Address - Phone:405-340-9949
Mailing Address - Fax:
Practice Address - Street 1:2505 S KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-340-9949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-04
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20347208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK700522163Medicare PIN