Provider Demographics
NPI:1659541043
Name:COSMETIC VEIN CENTERS OF VIRGINIA
Entity Type:Organization
Organization Name:COSMETIC VEIN CENTERS OF VIRGINIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:MACMILLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-552-8346
Mailing Address - Street 1:1901 S MAIN ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6600
Mailing Address - Country:US
Mailing Address - Phone:540-552-8346
Mailing Address - Fax:540-951-8346
Practice Address - Street 1:1901 S MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6600
Practice Address - Country:US
Practice Address - Phone:540-552-8346
Practice Address - Fax:540-951-8346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051292202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD91059Medicare UPIN
VAC09248Medicare PIN