Provider Demographics
NPI:1477905388
Name:VANGUARD SPECIALTY IMAGING
Entity Type:Organization
Organization Name:VANGUARD SPECIALTY IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:WERDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-722-6642
Mailing Address - Street 1:1345 LILLIAN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-3523
Mailing Address - Country:US
Mailing Address - Phone:415-722-6642
Mailing Address - Fax:
Practice Address - Street 1:1345 LILLIAN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-3523
Practice Address - Country:US
Practice Address - Phone:415-722-6642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84749174400000X, 2085R0202X, 2085R0204X, 208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G847493Medicare PIN