Healthcare Provider Details

I. General information

NPI: 1215407218
Provider Name (Legal Business Name): VASCULAR AND ENDOVASCULAR SURGERY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 SAMARITAN DR STE 503
SAN JOSE CA
95124-4015
US

IV. Provider business mailing address

1900 CAMDEN AVE STE 101
SAN JOSE CA
95124-2944
US

V. Phone/Fax

Practice location:
  • Phone: 408-558-3600
  • Fax: 408-614-2001
Mailing address:
  • Phone: 408-558-3600
  • Fax: 408-614-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ABID C MOGANNAM
Title or Position: VASCULAR SURGEON
Credential: MD
Phone: 408-899-8272