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
StateLicense IDTaxonomies
TXK02302084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD 00492Medicare UPIN
TX85400KMedicare ID - Type Unspecified
TXTXB103660Medicare PIN
TXTXB100940Medicare PIN
TXTXB103659Medicare PIN
TXTXB100941Medicare PIN