Provider Demographics
NPI:1821553108
Name:MODERN VASCULAR OF FAIRFAX, LLC
Entity Type:Organization
Organization Name:MODERN VASCULAR OF FAIRFAX, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YURY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAMPEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-880-8605
Mailing Address - Street 1:26500 AGOURA RD STE 102-587
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1952
Mailing Address - Country:US
Mailing Address - Phone:818-880-8605
Mailing Address - Fax:818-579-7916
Practice Address - Street 1:2812 OLD LEE HWY STE 100B
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4315
Practice Address - Country:US
Practice Address - Phone:571-279-6849
Practice Address - Fax:571-281-8697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional TechnologyGroup - Multi-Specialty