Basic Information
| Provider Information | |||||||||
| NPI: | 1144571076 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAN DIEGO DIAGNOSTIC RADIOLOGY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23540 | ||||||||
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| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921933540 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 15615 POMERADO RD | ||||||||
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| City: | POWAY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920642405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586134000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2012 | ||||||||
| LastUpdateDate: | 03/22/2017 | ||||||||
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| AuthorizedOfficialLastName: | CHEN | ||||||||
| AuthorizedOfficialFirstName: | NORMAN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8585650950 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.