Provider Demographics
NPI:1528049855
Name:CENTER FOR AESTHETIC AND RECONSTRUCTIVE EYELID AND ORBITAL SURGERY
Entity type:Organization
Organization Name:CENTER FOR AESTHETIC AND RECONSTRUCTIVE EYELID AND ORBITAL SURGERY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BLADYON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-458-2141
Mailing Address - Street 1:3705 MEDICAL PKWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1019
Mailing Address - Country:US
Mailing Address - Phone:512-458-4391
Mailing Address - Fax:512-458-5933
Practice Address - Street 1:3705 MEDICAL PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1019
Practice Address - Country:US
Practice Address - Phone:512-458-4391
Practice Address - Fax:512-458-5933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000352261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085968801Medicaid
TX451211Medicare PIN