Provider Demographics
NPI:1073747952
Name:TEXAS VASCULAR ASSOCIATES
Entity Type:Organization
Organization Name:TEXAS VASCULAR ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOLIVETTE WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:214-821-9600
Mailing Address - Street 1:4708 ALLIANCE BLVD
Mailing Address - Street 2:SUITE# 240
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5340
Mailing Address - Country:US
Mailing Address - Phone:214-821-9600
Mailing Address - Fax:214-823-5449
Practice Address - Street 1:4708 ALLIANCE BLVD
Practice Address - Street 2:SUITE# 240
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5340
Practice Address - Country:US
Practice Address - Phone:214-821-9600
Practice Address - Fax:214-823-5449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-07
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101289335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143448201Medicaid
TX143448201Medicaid