Provider Demographics
NPI:1952820979
Name:MODERN VEIN CLINIC
Entity Type:Organization
Organization Name:MODERN VEIN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NAZARIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-336-4454
Mailing Address - Street 1:757 8TH AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORTH WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-336-4454
Mailing Address - Fax:817-336-4440
Practice Address - Street 1:757 8TH AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:FORTH WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-336-4454
Practice Address - Fax:817-336-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-11
Last Update Date:2017-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7962207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty