Basic Information
| Provider Information | |||||||||
| NPI: | 1043328776 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS IMAGING GROUP LLC WEST OFFICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 147026 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326147026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523319729 | ||||||||
| FaxNumber: | 3523310136 | ||||||||
| Practice Location | |||||||||
| Address1: | 4960 W NEWBERRY RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326072200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523713336 | ||||||||
| FaxNumber: | 3523713372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WARE | ||||||||
| AuthorizedOfficialFirstName: | DAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/PRACTICING PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 3523319729 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085U0001X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound |
ID Information
| ID | Type | State | Issuer | Description | 45280 | 01 | FL | BC GROUP | OTHER | 270855 | 01 | FL | AVMED GROUP | OTHER | CK3155 | 01 | FL | RRMC GROUP | OTHER | V2766 | 01 | FL | BC IDTF | OTHER |