Healthcare Provider Details

I. General information

NPI: 1245739820
Provider Name (Legal Business Name): NORTHRIDGE VASCULAR CENTER A PROFESSIONAL MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 10/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19331 BUSINESS CENTER DR STE 102
NORTHRIDGE CA
91324-3533
US

IV. Provider business mailing address

10605 BALBOA BLVD STE 240
GRANADA HILLS CA
91344
US

V. Phone/Fax

Practice location:
  • Phone: 818-709-5555
  • Fax: 818-739-1465
Mailing address:
  • Phone: 424-241-7160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: VINOD ASSOMULL
Title or Position: PRESIDENT
Credential: MD
Phone: 424-241-7160