Provider Demographics
NPI:1497486245
Name:WESTERN VASCULAR A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:WESTERN VASCULAR A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-475-8611
Mailing Address - Street 1:PO BOX 9086
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92375-2286
Mailing Address - Country:US
Mailing Address - Phone:833-989-1009
Mailing Address - Fax:801-931-2044
Practice Address - Street 1:401 E HIGHLAND AVE STE 351
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3830
Practice Address - Country:US
Practice Address - Phone:833-989-1009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN BARIATRIC, A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty