Provider Demographics
NPI:1235443417
Name:WIREGRASS VASCULAR, P.C.
Entity Type:Organization
Organization Name:WIREGRASS VASCULAR, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:N
Authorized Official - Last Name:VEALE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD, MPH
Authorized Official - Phone:334-673-0049
Mailing Address - Street 1:112 HAVEN DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2907
Mailing Address - Country:US
Mailing Address - Phone:334-673-0049
Mailing Address - Fax:
Practice Address - Street 1:112 HAVEN DR
Practice Address - Street 2:SUITE 1
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2907
Practice Address - Country:US
Practice Address - Phone:334-673-0049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30278208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty