Healthcare Provider Details

I. General information

NPI: 1043174857
Provider Name (Legal Business Name): ADVANCED VASCULAR AND VEIN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 IRVIN WAY STE 101
DECATUR GA
30030-5405
US

IV. Provider business mailing address

1551 JANMAR RD
SNELLVILLE GA
30078-5606
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8900
  • Fax: 678-666-5201
Mailing address:
  • Phone: 470-579-5600
  • Fax: 678-691-0506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: BRADLEY WHITE
Title or Position: OWNER
Credential: DO
Phone: 239-223-9105