Healthcare Provider Details

I. General information

NPI: 1215255906
Provider Name (Legal Business Name): ENDOVASCULAR NEUROSURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 05/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9867 SASKATCHEWAN AVE
SAN DIEGO CA
92129-3506
US

IV. Provider business mailing address

9867 SASKATCHEWAN AVE
SAN DIEGO CA
92129-3506
US

V. Phone/Fax

Practice location:
  • Phone: 619-990-8212
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberA83715
License Number StateCA

VIII. Authorized Official

Name: SCOTT OLSON
Title or Position: PRESIDENT
Credential: MD
Phone: 619-990-8212