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General NPI Number Information
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NPI Number | 1104642214
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Entity Type | Organization
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Legal Business Name | DIAMOND STATE VASCULAR INTERVENTIONAL LLC
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Dates
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Enumeration Date | 11/25/2024
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Last Update Date | 11/25/2024
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Provider Practice Location Address
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Address Line | 1941 LIMESTONE RD STE 15
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City | WILMINGTON
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State | DE
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Zip | 19808-5423
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Country | US
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Telephone | 571-265-9715
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Fax |
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Provider Business Mailing Address
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Address Line | 9450 SW GEMINI DR STE 59742
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City | BEAVERTON
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State | OR
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Zip | 97008-7105
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Country | US
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Telephone | 571-265-9715
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Fax |
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Authorized Official
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Title or Position | STAFF
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Name | NILOY DASGUPTA
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Credential | MD
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Telephone | 571-265-9715
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0204X
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Taxonomy Name | Vascular & Interventional Radiology Physician
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License Number |
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License Number State |
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