Healthcare Provider Details

I. General information

NPI: 1972221182
Provider Name (Legal Business Name): ENDOVASCULAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 COLLEGE DR
GALLUP NM
87301-7003
US

IV. Provider business mailing address

202 E EARLL DR STE 360
PHOENIX AZ
85012-2677
US

V. Phone/Fax

Practice location:
  • Phone: 505-297-1052
  • Fax: 505-297-1227
Mailing address:
  • Phone: 480-788-5621
  • Fax: 480-779-1277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KIUP ALEXANDER KIM
Title or Position: CHIEF MEDICAL OFFICER
Credential: MD
Phone: 480-584-2369