Provider Demographics
NPI:1598820136
Name:PRESTIGE PLASTIC SURGERY, LLC
Entity Type:Organization
Organization Name:PRESTIGE PLASTIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:VELA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-290-1696
Mailing Address - Street 1:8600 SNOWDEN RIVER PKWY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-1982
Mailing Address - Country:US
Mailing Address - Phone:410-290-1696
Mailing Address - Fax:
Practice Address - Street 1:8600 SNOWDEN RIVER PKWY
Practice Address - Street 2:SUITE 308
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-1982
Practice Address - Country:US
Practice Address - Phone:410-290-1696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063900208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD30PZGAOtherBLUE CROSS BLUE SHIELD
MDI07162Medicare UPIN
MD467PMedicare PIN