MEDICARE: VASCULAR AND ENDOVASCULAR SURGERY, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician
2	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1215407218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VASCULAR AND ENDOVASCULAR SURGERY, PC

Provider Business Mailing Address
First Line	:	1900 CAMDEN AVE STE 101
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2944
Country	:	US
Telephone Number	:	408-558-3600
Fax Number	:	408-614-2001

Provider Business Practice Location Address
First Line	:	2505 SAMARITAN DR STE 503
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-4015
Country	:	US
Telephone Number	:	408-558-3600
Fax Number	:	408-614-2001

Authorized Official
Title or Position	:	VASCULAR SURGEON
Name	:	DR. ABID C MOGANNAM
Credential	:	MD
Telephone Number	:	408-899-8272

Provider Enumeration Date	:	12/03/2018
Last Update Date	:	12/04/2018

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