Provider Demographics
NPI:1093371163
Name:SAN ANTONIO VASCULAR SPECIALISTS CORP
Entity Type:Organization
Organization Name:SAN ANTONIO VASCULAR SPECIALISTS CORP
Other - Org Name:MODERN VASCULAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-262-6423
Mailing Address - Street 1:26500 AGOURA RD STE 102-587
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1952
Mailing Address - Country:US
Mailing Address - Phone:818-880-8605
Mailing Address - Fax:
Practice Address - Street 1:9819 HUEBNER RD BLDG 4
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-3253
Practice Address - Country:US
Practice Address - Phone:210-761-8775
Practice Address - Fax:210-519-0216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-14
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional TechnologyGroup - Multi-Specialty