Provider Demographics
NPI:1508964024
Name:ADVANCED VEIN THERAPEUTICS
Entity Type:Organization
Organization Name:ADVANCED VEIN THERAPEUTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SURINDRA
Authorized Official - Middle Name:N
Authorized Official - Last Name:MITRUKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-568-4361
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:K108
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270
Mailing Address - Country:US
Mailing Address - Phone:760-568-3461
Mailing Address - Fax:760-568-6470
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:K108
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270
Practice Address - Country:US
Practice Address - Phone:760-568-3461
Practice Address - Fax:760-568-6470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ28852ZMedicare ID - Type Unspecified