Healthcare Provider Details

I. General information

NPI: 1821553108
Provider Name (Legal Business Name): MODERN VASCULAR OF FAIRFAX, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2019
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 OLD LEE HWY STE 100B
FAIRFAX VA
22031-4315
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 571-279-6849
  • Fax: 571-281-8697
Mailing address:
  • Phone: 818-880-8605
  • Fax: 818-579-7916

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: YURY GAMPEL
Title or Position: MANAGER
Credential:
Phone: 818-880-8605