Basic Information
| Provider Information | |||||||||
| NPI: | 1336781236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERFORD VASCULAR ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 BUTTERFIELD RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | DOWNERS GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605151069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6307252700 | ||||||||
| FaxNumber: | 8338425469 | ||||||||
| Practice Location | |||||||||
| Address1: | 903 HARTFORD TPKE UNIT 30 | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063854264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607721998 | ||||||||
| FaxNumber: | 8607721999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2019 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| AuthorizedOfficialLastName: | ESPARZA | ||||||||
| AuthorizedOfficialFirstName: | LORENA | ||||||||
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| AuthorizedOfficialTitleorPosition: | REVENUE CYCLE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6307252764 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.