Healthcare Provider Details

I. General information

NPI: 1669863981
Provider Name (Legal Business Name): PEDES VASCULAR SAN FERNANDO VALLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2015
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16260 VENTURA BOULEVARD SUITE 210
ENCINO CA
91436-2203
US

IV. Provider business mailing address

16260 VENTURA BOULEVARD SUITE 210
ENCINO CA
91436-2203
US

V. Phone/Fax

Practice location:
  • Phone: 949-394-5018
  • Fax:
Mailing address:
  • Phone: 949-394-5018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberC52896
License Number StateCA

VIII. Authorized Official

Name: JOHN JOSEPH HEWETT
Title or Position: OWNER
Credential: M.D
Phone: 424-500-2557