Provider Demographics
NPI:1093273781
Name:SOUTHWEST VASCULAR P.C.
Entity Type:Organization
Organization Name:SOUTHWEST VASCULAR P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVIDENZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-614-9552
Mailing Address - Street 1:2737 SOUTH HULEN STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109
Mailing Address - Country:US
Mailing Address - Phone:817-770-0608
Mailing Address - Fax:
Practice Address - Street 1:4375 BOOTH CALLAWAY SUITE 501
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76180
Practice Address - Country:US
Practice Address - Phone:817-770-0608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty