Provider Demographics
NPI:1851668925
Name:FORT WORTH VASCULAR AND SURGICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:FORT WORTH VASCULAR AND SURGICAL ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:E
Authorized Official - Last Name:PROVIDENZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-614-9552
Mailing Address - Street 1:2737 S HULEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-9535
Mailing Address - Country:US
Mailing Address - Phone:817-927-5627
Mailing Address - Fax:817-927-7568
Practice Address - Street 1:2737 S HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-9535
Practice Address - Country:US
Practice Address - Phone:817-332-7544
Practice Address - Fax:817-338-9441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-17
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ69802086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty