Provider Demographics
NPI:1730380775
Name:WEST SIDE PLASTIC SURGERY, INC
Entity type:Organization
Organization Name:WEST SIDE PLASTIC SURGERY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VETRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GIPSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-805-0646
Mailing Address - Street 1:4480 S COBB DR SE STE H
Mailing Address - Street 2:BOX 323
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-6984
Mailing Address - Country:US
Mailing Address - Phone:404-805-5535
Mailing Address - Fax:866-935-5995
Practice Address - Street 1:960 JOHNSON FERRY RD N.E.
Practice Address - Street 2:SUITE 336
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-805-5535
Practice Address - Fax:866-935-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA505182086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000963102BMedicaid
GAH59132Medicare UPIN
GAGRP7295Medicare ID - Type Unspecified