Provider Demographics
NPI:1083725634
Name:DALLAS VEIN CENTER, PA
Entity Type:Organization
Organization Name:DALLAS VEIN CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDIC
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHANIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-738-3780
Mailing Address - Street 1:2555 N PEARL ST APT 303
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-2244
Mailing Address - Country:US
Mailing Address - Phone:214-738-3780
Mailing Address - Fax:972-426-9899
Practice Address - Street 1:618 CLARA BARTON
Practice Address - Street 2:SUITE #1
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042
Practice Address - Country:US
Practice Address - Phone:972-475-6683
Practice Address - Fax:972-475-7648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ62562086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y546Medicare UPIN