=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467995514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDOVASCULAR CONSULTANTS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2016
-----------------------------------------------------
Last Update Date | 01/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 S ASHVIEW LN
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19807-2171
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-275-1867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 N CLAYTON ST STE 601
-----------------------------------------------------
City | WILMINGTON
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19805-3165
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-575-8368
-----------------------------------------------------
Fax | 302-225-8778
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARK GARCIA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 302-275-1867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0204X
-----------------------------------------------------
Taxonomy Name | Vascular & Interventional Radiology Physician
-----------------------------------------------------
License Number | C1-0004350
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------