Provider Demographics
NPI:1720569817
Name:FUSTOK COSMETIC AND RECONSTRUCTIVE SURGERY PA
Entity type:Organization
Organization Name:FUSTOK COSMETIC AND RECONSTRUCTIVE SURGERY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNI
Authorized Official - Middle Name:
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-621-2950
Mailing Address - Street 1:333 WEST LOOP N STE 410
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77024-7709
Mailing Address - Country:US
Mailing Address - Phone:713-621-2950
Mailing Address - Fax:713-589-2011
Practice Address - Street 1:333 WEST LOOP N STE 410
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-7709
Practice Address - Country:US
Practice Address - Phone:713-621-2950
Practice Address - Fax:713-589-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-27
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF47272086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF4727OtherSTATE LICENSE