MEDICARE: FORT WORTH VASCULAR SPECIALISTS CORP

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	2471V0106X	Vascular-Interventional Technology Radiologic Technologist
2	2085R0204X	Vascular & Interventional Radiology Physician

General Provider Information

NPI Number	:	1396370334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH VASCULAR SPECIALISTS CORP

Provider Business Mailing Address
First Line	:	26500 AGOURA RD STE 102-587
Second Line	:
City	:	CALABASAS
State	:	CA
Zip	:	91302-1952
Country	:	US
Telephone Number	:	818-880-8605
Fax Number	:	818-579-7916

Provider Business Practice Location Address
First Line	:	5750 STRATUM DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-2757
Country	:	US
Telephone Number	:	817-989-2580
Fax Number	:	817-989-6555

Authorized Official
Title or Position	:	MANAGER
Name	:	YURY GAMPEL
Credential	:
Telephone Number	:	818-880-8605

Provider Enumeration Date	:	03/10/2020
Last Update Date	:	06/05/2020

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