Healthcare Provider Details

I. General information

NPI: 1285095083
Provider Name (Legal Business Name): ELYSIAN PLASTIC SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2016
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11623 ANGUS RD SUITE C15
AUSTIN TX
78759-4003
US

IV. Provider business mailing address

11623 ANGUS RD SUITE C15
AUSTIN TX
78759-4003
US

V. Phone/Fax

Practice location:
  • Phone: 512-229-1978
  • Fax: 512-402-5409
Mailing address:
  • Phone: 512-229-1978
  • Fax: 512-402-5409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberBD2335188
License Number StateTX

VIII. Authorized Official

Name: DAVID DELLINGER
Title or Position: OWNER
Credential: DO
Phone: 512-229-1978