Provider Demographics
NPI:1508108887
Name:ELITE PLASTIC & RECONSTRUCTIVE SURGERY, PA
Entity Type:Organization
Organization Name:ELITE PLASTIC & RECONSTRUCTIVE SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MD
Authorized Official - Prefix:DR
Authorized Official - First Name:DEOWALL
Authorized Official - Middle Name:
Authorized Official - Last Name:CHATTER-CORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-265-1924
Mailing Address - Street 1:11212 STATE HIGHWAY 151
Mailing Address - Street 2:MEDICAL PLAZA #2 SUITE 230
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78251-4498
Mailing Address - Country:US
Mailing Address - Phone:210-265-1924
Mailing Address - Fax:210-265-3387
Practice Address - Street 1:11212 STATE HIGHWAY 151
Practice Address - Street 2:MEDICAL PLAZA #2 SUITE 230
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-4498
Practice Address - Country:US
Practice Address - Phone:210-265-1924
Practice Address - Fax:210-265-3387
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-25
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM34962086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX313312OtherPTAN