# MODERN VASCULAR OF GLENDALE, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1063947638
- **Authorized official:** YURY GAMPEL (MANAGER)
- **Authorized official phone:** (818) 880-8605

## Contact information

- **Practice address:** 11851 N 51ST AVE, BUILDING G, GLENDALE, AZ 85304
- **Practice address phone:** (818) 949-2634
- **Mailing address:** 26500 AGOURA RD STE 102-587, CALABASAS, CA 91302-1952
- **Mailing address phone:** (818) 880-8605

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | — |
| 207Q00000X | Family Medicine Physician | — | — | — |
| 207RC0000X | Cardiovascular Disease Physician | — | NULL | — |
| 207RC0000X | Cardiovascular Disease Physician | — | — | — |
| 207RI0011X | Interventional Cardiology Physician | — | NULL | — |
| 207RI0011X | Interventional Cardiology Physician | — | — | — |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | NULL | Yes |
| 2085R0204X | Vascular & Interventional Radiology Physician | — | — | Yes |
| 213E00000X | Podiatrist | — | NULL | — |
| 213E00000X | Podiatrist | — | — | — |

## Other

- **Enumeration date:** 04/20/2017
- **Last updated:** 07/11/2018