Basic Information
| Provider Information | |||||||||
| NPI: | 1467735084 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ONTARIO RADIOLOGY PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 405 N FRENCH RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142282010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166891901 | ||||||||
| FaxNumber: | 7165640209 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 COULTER RD | ||||||||
| Address2: | |||||||||
| City: | CLIFTON SPRINGS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 144321122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166891901 | ||||||||
| FaxNumber: | 7165640209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 05/08/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOOTORABI | ||||||||
| AuthorizedOfficialFirstName: | BAKTASH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MD/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3154629561 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.