Healthcare Provider Details

I. General information

NPI: 1912259698
Provider Name (Legal Business Name): LAKE JACKSON PLASTIC SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 OAK DR S SUITE J
LAKE JACKSON TX
77566-5629
US

IV. Provider business mailing address

10565 KATY FWY SUITE 100
HOUSTON TX
77024-1007
US

V. Phone/Fax

Practice location:
  • Phone: 979-480-0105
  • Fax: 979-480-0106
Mailing address:
  • Phone: 713-467-0146
  • Fax: 713-467-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberH2191
License Number StateTX

VIII. Authorized Official

Name: DR. ROBERT SCOTT YARISH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 713-467-0146