Healthcare Provider Details

I. General information

NPI: 1659285724
Provider Name (Legal Business Name): PEDES VASCULAR INSTITUTE LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

323 N PRAIRIE AVE STE 114
INGLEWOOD CA
90301-4503
US

IV. Provider business mailing address

2549 EASTBLUFF DR STE 337
NEWPORT BEACH CA
92660-3500
US

V. Phone/Fax

Practice location:
  • Phone: 949-391-1490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: CAMILA AGAN
Title or Position: CENTER MANAGER
Credential:
Phone: 949-391-1490