Provider Demographics
NPI:1407953771
Name:VASCULAR SURGERY ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:VASCULAR SURGERY ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:850-877-8539
Mailing Address - Street 1:2631 CENTENNIAL BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0588
Mailing Address - Country:US
Mailing Address - Phone:850-877-8539
Mailing Address - Fax:850-877-6674
Practice Address - Street 1:2631 CENTENNIAL BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0588
Practice Address - Country:US
Practice Address - Phone:850-877-8539
Practice Address - Fax:850-877-6674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL255471200Medicaid
GA300038191AMedicaid
GA300038191AMedicaid