Provider Demographics
NPI:1477714764
Name:MIDWEST VEIN & LASER CENTER OF LIMA
Entity Type:Organization
Organization Name:MIDWEST VEIN & LASER CENTER OF LIMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-222-8346
Mailing Address - Street 1:770 W HIGH ST
Mailing Address - Street 2:SUITE 420
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-3990
Mailing Address - Country:US
Mailing Address - Phone:419-222-8346
Mailing Address - Fax:419-225-8549
Practice Address - Street 1:770 W HIGH ST
Practice Address - Street 2:SUITE 420
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-3990
Practice Address - Country:US
Practice Address - Phone:419-222-8346
Practice Address - Fax:419-225-8549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0502442086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty