Provider Demographics
NPI:1972221182
Name:ENDOVASCULAR
Entity Type:Organization
Organization Name:ENDOVASCULAR
Other - Org Name:ENDOVASCULAR
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:KIUP
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-584-2369
Mailing Address - Street 1:202 E EARLL DR STE 360
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2677
Mailing Address - Country:US
Mailing Address - Phone:480-788-5621
Mailing Address - Fax:480-779-1277
Practice Address - Street 1:2240 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-7003
Practice Address - Country:US
Practice Address - Phone:505-297-1052
Practice Address - Fax:505-297-1227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-15
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty