Healthcare Provider Details

I. General information

NPI: 1063947638
Provider Name (Legal Business Name): MODERN VASCULAR OF GLENDALE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 07/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11851 N 51ST AVE BUILDING G
GLENDALE AZ
85304
US

IV. Provider business mailing address

26500 AGOURA RD STE 102-587
CALABASAS CA
91302-1952
US

V. Phone/Fax

Practice location:
  • Phone: 818-949-2634
  • Fax:
Mailing address:
  • Phone: 818-880-8605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: YURY GAMPEL
Title or Position: MANAGER
Credential:
Phone: 818-880-8605