Basic Information
| Provider Information | |||||||||
| NPI: | 1154991743 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR VEIN RESTORATION DE LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR STE 1000 | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
| FaxNumber: | 2404734321 | ||||||||
| Practice Location | |||||||||
| Address1: | 19606 COASTAL HWY UNIT 203 | ||||||||
| Address2: | |||||||||
| City: | REHOBOTH BEACH | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199718577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
| FaxNumber: | 2404734321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2021 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAKHANPAL | ||||||||
| AuthorizedOfficialFirstName: | SANJIV | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8558308346 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.