Provider Demographics
NPI: | 1932198025 |
---|---|
Name: | VENGROW, MICHAEL IAN (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MICHAEL |
Middle Name: | IAN |
Last Name: | VENGROW |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 5977 TEMPLE DR |
Mailing Address - Street 2: | |
Mailing Address - City: | PLANO |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75093-8707 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 214-850-6336 |
Mailing Address - Fax: | 972-473-8051 |
Practice Address - Street 1: | 5977 TEMPLE DR |
Practice Address - Street 2: | |
Practice Address - City: | PLANO |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75093-8707 |
Practice Address - Country: | US |
Practice Address - Phone: | 214-850-6336 |
Practice Address - Fax: | 972-473-8051 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2005-10-20 |
Last Update Date: | 2012-01-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | K0230 | 2084N0600X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084N0600X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | D 00492 | Medicare UPIN | |
TX | 85400K | Medicare ID - Type Unspecified | |
TX | TXB103660 | Medicare PIN | |
TX | TXB100940 | Medicare PIN | |
TX | TXB103659 | Medicare PIN | |
TX | TXB100941 | Medicare PIN |