Basic Information
| Provider Information | |||||||||
| NPI: | 1144262817 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAN GABRIEL VIP A CALIFORNIA LIMITED PARTNERSHIP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | VALLEY IMAGING PARTNERSHIP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917930635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268139988 | ||||||||
| FaxNumber: | 6268130075 | ||||||||
| Practice Location | |||||||||
| Address1: | 1115 S SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268139988 | ||||||||
| FaxNumber: | 6268130075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 06/17/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAISERMAN | ||||||||
| AuthorizedOfficialFirstName: | DONALD | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6268139988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | BCBS | 01 | CA | ZZZ25286Z | OTHER | GR0058270 | 05 | CA | MEDICAID | CQ2233 | 01 | CA | MEDICARE RR | OTHER |