Provider Demographics
NPI:1598938250
Name:SPACE COAST VASCULAR INC
Entity Type:Organization
Organization Name:SPACE COAST VASCULAR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:S
Authorized Official - Last Name:DOVGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-751-2707
Mailing Address - Street 1:655 S APOLLO BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1485
Mailing Address - Country:US
Mailing Address - Phone:321-751-2707
Mailing Address - Fax:321-255-2361
Practice Address - Street 1:655 S APOLLO BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1485
Practice Address - Country:US
Practice Address - Phone:321-751-2707
Practice Address - Fax:321-255-2361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8939Medicare PIN