Healthcare Provider Details

I. General information

NPI: 1477905388
Provider Name (Legal Business Name): VANGUARD SPECIALTY IMAGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2016
Last Update Date: 07/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 LILLIAN AVE
SUNNYVALE CA
94087-3523
US

IV. Provider business mailing address

1345 LILLIAN AVE
SUNNYVALE CA
94087-3523
US

V. Phone/Fax

Practice location:
  • Phone: 415-722-6642
  • Fax:
Mailing address:
  • Phone: 415-722-6642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG84749
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG84749
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG84749
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG84749
License Number StateCA

VIII. Authorized Official

Name: DR. SCOTT WERDEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 415-722-6642