Provider Demographics
NPI:1609133511
Name:PERIPHERAL VASCULAR ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PERIPHERAL VASCULAR ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:S
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-221-0136
Mailing Address - Street 1:PO BOX 12139
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-5053
Mailing Address - Country:US
Mailing Address - Phone:949-922-2352
Mailing Address - Fax:949-223-4702
Practice Address - Street 1:4501 BIRCH ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1990
Practice Address - Country:US
Practice Address - Phone:949-922-2352
Practice Address - Fax:949-223-4702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1051212086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty