Basic Information
Provider Information | |||||||||
NPI: | 1275523169 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL VALLEY IMAGING MEDICAL ASSOCIATES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 398076 | ||||||||
Address2: |   | ||||||||
City: | SAN FRANCISCO | ||||||||
State: | CA | ||||||||
PostalCode: | 941398076 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2096472184 | ||||||||
FaxNumber: | 2096474684 | ||||||||
Practice Location | |||||||||
Address1: | 250 CHERRY LN STE 116 | ||||||||
Address2: |   | ||||||||
City: | MANTECA | ||||||||
State: | CA | ||||||||
PostalCode: | 953374398 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2096472184 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2005 | ||||||||
LastUpdateDate: | 07/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PORZIO | ||||||||
AuthorizedOfficialFirstName: | RICHARD | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2096472184 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 71935 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | GR0092114 | 05 | CA |   | MEDICAID | ZZZ65959Z | 01 | CA | BLUE SHIELD | OTHER | GR0092113 | 05 | CA |   | MEDICAID | ZZZ08287Z | 01 | CA | BLUE SHIELD | OTHER | GR0092110 | 05 | CA |   | MEDICAID | GR0092111 | 05 | CA |   | MEDICAID | ZZZ05093Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ05094Z | 01 | CA | BLUE SHIELD | OTHER |