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General NPI Number Information
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NPI Number | 1134966286
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Entity Type | Organization
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Legal Business Name | DOMINION VASCULAR SURGICAL SPECIALISTS
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Dates
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Enumeration Date | 07/15/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 1355 S INTERNATIONAL PKWY STE 1491
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City | LAKE MARY
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State | FL
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Zip | 32746-1694
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Country | US
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Telephone | 40-754-3641
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Fax |
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Provider Business Mailing Address
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Address Line | 4300 W LAKE MARY BLVD STE 1010
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City | LAKE MARY
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State | FL
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Zip | 32746-2449
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Country | US
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Telephone | 347-829-0399
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Fax |
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Authorized Official
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Title or Position | DR.
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Name | DR. OLUBUNMI OLATAYO ESAN
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Credential | MD
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Telephone | 347-829-0399
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2086S0129X
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Taxonomy Name | Vascular Surgery Physician
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License Number |
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License Number State |
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