Provider Demographics
NPI:1114919065
Name:DVL VASCULAR LAB INC
Entity Type:Organization
Organization Name:DVL VASCULAR LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:KAYE
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:RVT
Authorized Official - Phone:937-220-9934
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-0276
Mailing Address - Country:US
Mailing Address - Phone:937-220-9934
Mailing Address - Fax:937-220-9936
Practice Address - Street 1:627 S EDWIN C MOSES BLVD
Practice Address - Street 2:SUITE 3H
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-3461
Practice Address - Country:US
Practice Address - Phone:937-220-9934
Practice Address - Fax:937-220-9936
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH8047042085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0872793Medicaid
OH0872793Medicaid