Provider Demographics
NPI:1609646066
Name:NUTLEY VASCULAR CLINIC
Entity Type:Organization
Organization Name:NUTLEY VASCULAR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:ODEH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-242-9621
Mailing Address - Street 1:410 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-1635
Mailing Address - Country:US
Mailing Address - Phone:404-242-9621
Mailing Address - Fax:845-362-8474
Practice Address - Street 1:410 CENTRE ST
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-1635
Practice Address - Country:US
Practice Address - Phone:404-242-9621
Practice Address - Fax:845-362-8474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty