MEDICARE: ALI REZA ABTAHI D.O.

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	2086S0122X	Plastic and Reconstructive Surgery Physician	T0683	TX
2	390200000X	Student in an Organized Health Care Education/Training Program
3	2086S0122X	Plastic and Reconstructive Surgery Physician	01086289A	IN

General Provider Information

NPI Number	:	1518224401
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALI REZA ABTAHI D.O.

Provider Business Mailing Address
First Line	:	11816 INWOOD RD # 1400
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75244-8011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5288 TOWNE SQUARE DR STE 150
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-0037
Country	:	US
Telephone Number	:	469-293-8707
Fax Number	:	469-294-8707

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/16/2012
Last Update Date	:	10/18/2023

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