Provider Demographics
NPI:1548575707
Name:PLASTIC SURGERY OF NORTHEAST SAN ANTONIO
Entity Type:Organization
Organization Name:PLASTIC SURGERY OF NORTHEAST SAN ANTONIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.'S ASSISTANT/ BILLING PERSONEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-656-4216
Mailing Address - Street 1:19315 NACOGDOCHES RD
Mailing Address - Street 2:STE. 305
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2516
Mailing Address - Country:US
Mailing Address - Phone:210-656-4216
Mailing Address - Fax:210-656-4217
Practice Address - Street 1:19315 NACOGDOCHES RD
Practice Address - Street 2:STE. 305
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78266-2516
Practice Address - Country:US
Practice Address - Phone:210-656-4216
Practice Address - Fax:210-656-4217
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENZER J DIRKSON MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-08-12
Last Update Date:2010-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK7278302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX127561201Medicaid
TX00632JMedicare UPIN