Basic Information
| Provider Information | |||||||||
| NPI: | 1346712650 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR VEIN RESTORATION TX LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7474 GREENWAY CENTER DR STE 1000 | ||||||||
| Address2: | |||||||||
| City: | GREENBELT | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207703500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7900 FARM TO MARKET ROAD 1826 | ||||||||
| Address2: | BUILDING 1 SUITE 170 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787358977 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558308346 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2018 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| AuthorizedOfficialLastName: | GUPTA | ||||||||
| AuthorizedOfficialFirstName: | ADITYA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8558308346 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 02/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0589292 | 05 | NJ | MEDICAID |