Provider Demographics
NPI:1275922734
Name:MP PLASTIC SURGERY PLLC
Entity Type:Organization
Organization Name:MP PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAXIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PEKAREV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-529-9199
Mailing Address - Street 1:800 8TH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2619
Mailing Address - Country:US
Mailing Address - Phone:817-529-9199
Mailing Address - Fax:817-334-0491
Practice Address - Street 1:800 8TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2619
Practice Address - Country:US
Practice Address - Phone:817-529-9199
Practice Address - Fax:817-334-0491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP5223208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX328016601Medicaid
TX318210Medicare PIN