MEDICARE: ADVANCED RECONSTRUCTIVE PLASTIC SURGERY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1013840008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANCED RECONSTRUCTIVE PLASTIC SURGERY PLLC

Provider Business Mailing Address
First Line	:	1900 E STATE HIGHWAY 114 STE 140
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-6510
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 E STATE HIGHWAY 114 STE 140
Second Line	:
City	:	SOUTHLAKE
State	:	TX
Zip	:	76092-6510
Country	:	US
Telephone Number	:	469-293-2533
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	ALI REZA ABTAHI
Credential	:	DO
Telephone Number	:	469-293-2533

Provider Enumeration Date	:	06/08/2026
Last Update Date	:	06/08/2026

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