Provider Demographics
NPI:1255520714
Name:FORT MYERS CENTRE FOR FACIAL PLASTIC AND LASER SURGERY, INC.
Entity type:Organization
Organization Name:FORT MYERS CENTRE FOR FACIAL PLASTIC AND LASER SURGERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-481-4911
Mailing Address - Street 1:15721 NEW HAMPSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4176
Mailing Address - Country:US
Mailing Address - Phone:239-481-4911
Mailing Address - Fax:239-481-6360
Practice Address - Street 1:15721 NEW HAMPSHIRE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4176
Practice Address - Country:US
Practice Address - Phone:239-481-4911
Practice Address - Fax:239-481-6360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-22
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068103174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL040012514OtherRAILROAD MEDICARE
FL32891OtherBCBS
FL5091536OtherAETNA
FL32891OtherBCBS
FL040012514OtherRAILROAD MEDICARE