Healthcare Provider Details

I. General information

NPI: 1205289493
Provider Name (Legal Business Name): IMPERIAL ENDOVASCULAR PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 W LEGION RD
BRAWLEY CA
92227-7780
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 818-634-0936
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SHAHROUZ TAHVILIAN
Title or Position: OWNER
Credential: MD
Phone: 818-634-0936