Healthcare Provider Details

I. General information

NPI: 1366782294
Provider Name (Legal Business Name): PRESTIGE COSMETIC SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 03/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18707 HARDY OAK BLVD STE 455
SAN ANTONIO TX
78258-4841
US

IV. Provider business mailing address

18707 HARDY OAK BLVD STE 455
SAN ANTONIO TX
78258-4841
US

V. Phone/Fax

Practice location:
  • Phone: 210-255-1764
  • Fax: 210-255-8891
Mailing address:
  • Phone: 210-255-1764
  • Fax: 210-255-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberK3597
License Number StateTX

VIII. Authorized Official

Name: DR. BERNARD KOPCHINSKI
Title or Position: PRESIDENT, PLASTIC SURGEON
Credential: MD, FACS
Phone: 210-255-1764