Provider Demographics
NPI:1326408329
Name:ADVANCED AESTHETICS OF TEXAS, PLLC
Entity Type:Organization
Organization Name:ADVANCED AESTHETICS OF TEXAS, PLLC
Other - Org Name:ADVANCED AESTHETICS LOPEZ PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LOPEZ
Authorized Official - Middle Name:ANTONIO
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-495-5771
Mailing Address - Street 1:PO BOX 591819
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78259-0140
Mailing Address - Country:US
Mailing Address - Phone:210-495-5771
Mailing Address - Fax:210-966-9106
Practice Address - Street 1:18322 SONTERRA PL STE 107
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4196
Practice Address - Country:US
Practice Address - Phone:210-495-5771
Practice Address - Fax:210-966-9105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-03
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2695174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX486624Medicare PIN