Provider Demographics
NPI:1497062830
Name:ADVANCED VEIN & VASCULAR ASSOCIATES
Entity Type:Organization
Organization Name:ADVANCED VEIN & VASCULAR ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HUMAM
Authorized Official - Middle Name:BASSAM
Authorized Official - Last Name:KAKISH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-547-1142
Mailing Address - Street 1:8210 WALNUT HILL LN
Mailing Address - Street 2:SUITE 408
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4405
Mailing Address - Country:US
Mailing Address - Phone:469-547-1142
Mailing Address - Fax:469-547-1162
Practice Address - Street 1:8210 WALNUT HILL LN
Practice Address - Street 2:SUITE 408
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4405
Practice Address - Country:US
Practice Address - Phone:469-547-1142
Practice Address - Fax:469-547-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK08532086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG19502Medicare UPIN