Provider Demographics
NPI:1679981492
Name:NORTH TEXAS VASCULAR CENTER PA
Entity type:Organization
Organization Name:NORTH TEXAS VASCULAR CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-953-7451
Mailing Address - Street 1:3865 CHILDRESS AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-2802
Mailing Address - Country:US
Mailing Address - Phone:972-885-8346
Mailing Address - Fax:214-466-1976
Practice Address - Street 1:3865 CHILDRESS AVE
Practice Address - Street 2:SUITE C
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-2802
Practice Address - Country:US
Practice Address - Phone:972-885-8346
Practice Address - Fax:214-466-1976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1900208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty