Provider Demographics
NPI:1356982870
Name:VISTA PLASTIC SURGERY
Entity type:Organization
Organization Name:VISTA PLASTIC SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:BOOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-755-8478
Mailing Address - Street 1:4701 BEE CAVE RD
Mailing Address - Street 2:STE 202
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5366
Mailing Address - Country:US
Mailing Address - Phone:512-755-8478
Mailing Address - Fax:512-572-8484
Practice Address - Street 1:4701 BEE CAVE RD
Practice Address - Street 2:STE 202
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5366
Practice Address - Country:US
Practice Address - Phone:512-755-8478
Practice Address - Fax:512-572-8484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-06
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1447570916OtherNPI