Healthcare Provider Details

I. General information

NPI: 1225062490
Provider Name (Legal Business Name): UNIVERSITY VASCULAR ASSOCIATES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1082 GLENDON AVE
LOS ANGELES CA
90024-2908
US

IV. Provider business mailing address

1082 GLENDON AVE
LOS ANGELES CA
90024-2908
US

V. Phone/Fax

Practice location:
  • Phone: 310-209-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SAM S AHN
Title or Position: PRESIDENT
Credential: MD
Phone: 310-209-2011