Provider Demographics
NPI:1255519344
Name:SOUTHLAKE PLASTIC SURGERY
Entity type:Organization
Organization Name:SOUTHLAKE PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-442-8900
Mailing Address - Street 1:900 E SOUTHLAKE BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6375
Mailing Address - Country:US
Mailing Address - Phone:817-442-8900
Mailing Address - Fax:817-488-2490
Practice Address - Street 1:900 E SOUTHLAKE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6375
Practice Address - Country:US
Practice Address - Phone:817-442-8900
Practice Address - Fax:817-488-2490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4330204E00000X
208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0037EMOtherBCBSTX GRP NUMBER
00817NMedicare PIN