Healthcare Provider Details

I. General information

NPI: 1164037289
Provider Name (Legal Business Name): INDIANAPOLIS VASCULAR SPECIALISTS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8704 N MERIDIAN ST
INDIANAPOLIS IN
46260-2331
US

IV. Provider business mailing address

26500 AGOURA RD STE 102-587
CALABASAS CA
91302-1952
US

V. Phone/Fax

Practice location:
  • Phone: 463-207-1430
  • Fax: 463-800-3385
Mailing address:
  • Phone: 818-880-8605
  • 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 Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name: YURY GAMPEL
Title or Position: MANAGER
Credential:
Phone: 818-262-6423