Provider Demographics
NPI:1710408638
Name:I VASCULAR CENTER OF EL PASO PLLC
Entity Type:Organization
Organization Name:I VASCULAR CENTER OF EL PASO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANWAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GERGES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-240-9996
Mailing Address - Street 1:19234 STONEHUE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11989 PELLICANO DR STE D
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6288
Practice Address - Country:US
Practice Address - Phone:210-240-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207RN0300X
TXJ5769207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX117880808Medicaid